Objectives: Tamoxifen has been found to reduce the risk of invasive breast cancer by 45% compared to placebo. We sought to determine whether women are interested in taking a drug to prevent breast cancer and to assess the relationship between objective and subjective breast cancer risk and interest in chemoprevention.

Methods: A cross-sectional survey of a community sample of 1,273 women ages 40-44 and 50-54 enrolled in a randomized controlled trial to evaluate the efficacy of a tailored mammography decision-aid. Using a telephone interview, November 1997-February 1998, interest in chemoprevention for breast cancer was measured. Objective breast cancer risk was measured using the 10-year Gail Score (current age, age at menarche, mother/sisters with breast cancer, age at first live birth, and number of breast biopsies including any with atypical hyperplasia). Subjective breast cancer risk was measured using perceptions of absolute risk, perceptions of comparative risk, and worry about getting breast cancer. We performed bivariate and multivariate analyses for both pre-menopausal (40-44) and post-menopausal (50-54) age groups using interest in chemoprevention for breast cancer as the outcome variable.

Results: Among the 573 women ages 40-44, 21% was interested in chemoprevention for breast cancer, 50% were not interested and 29% were undecided. Factors that were significantly associated with an interest in breast cancer chemoprevention for this age group included: education, current smoking status, depressive symptoms, perceptions of comparative risk, and worry about getting breast cancer (p<0.05). The Gail Score, an objective measure of breast cancer risk, was not associated with an interest in chemoprevention. In logistic analyses, worry about breast cancer, current smoking status and depressive symptoms were significantly associated with an interest in chemoprevention. Among the 579 women ages 50-54, 24% was interested in chemoprevention for breast cancer, 50% were not interested and 26% were undecided. Factors that were significantly associated with an interest in breast cancer chemoprevention for this age group included: perceptions of comparative risk, and worry about getting breast cancer (p<0.05). The Gail Score was not associated with an interest in chemoprevention. In logistic analyses, worry about breast cancer and perceptions of comparative risk were significantly associated with an interest in chemoprevention.

Conclusions: We found a higher than expected (>20%) level of interest in chemoprevention for breast cancer. Given the new indication for tamoxifen as a breast cancer chemoprevention agent, health care providers will need to initiate a discussion about this controversial medical decision with their patients. Our research suggests that patients may base their interest in chemoprevention on their worry about getting breast cancer instead of objective risk factors.

Impact: This research has implications for the VA because women veterans may request information on chemoprevention for breast cancer based on their worry about getting breast cancer. We propose that women will need extensive counseling in order to determine their objective breast cancer risk and to understand the risk and benefits of taking tamoxifen for breast cancer prevention.

2. Quality of Life in Ambulatory Veterans with Alcohol Disorders: Does Abstinence Matter?

Dorcas Mansell, MD, MPH, University of Alabama Birmingham and Birmingham VAMC, Birmingham, AL, A Spiro III, CHQOER, Bedford VAMC and Boston University School of Public Health, C Hankin, CHQOER, Bedford VAMC, A Lee and L. Kazis, CHQOER, Bedford VAMC and Boston University

Objectives: Little is known about the role of abstinence in health related quality of life and health status for primary care patients with alcohol disorders. We describe the roles of abstinence in health status for veterans with alcohol disorders in ambulatory care.

Methods: Cross-sectional sample and survey of males who use VA ambulatory services in the greater Boston area. Alcohol disorders were classified as current alcohol disorders (CAGE>=2 and having had a drink in past year), former alcohol disorders (CAGE >=2 and no drink in past year) and no alcohol disorders (CAGE score of 0 and no prior treatment for substance abuse). Treatment was defined as any patient report of treatment. Health status was measured with the SF-36 from the Medical Outcomes Study with two summary scores, PCS (physical component summary scale) and MCS (mental component summary scale). Higher scores denote better function. Patients with current alcohol disorders completed the alcohol section of the QDIS, a diagnostic interview for DSM-III-R. ANCOVA was used to adjust PCS and MCS for age, marital status, education, physical and psychiatric comorbidities. Tukey's test was used for between group comparisons.

Results: 2425 of 4236 (57%) of eligible patients completed the survey. 310 had current alcohol disorders, 194 had former alcohol disorders, 1460 had no alcohol disorders (63 had history of treatment but CAGE=0, 328 had CAGE=1 and 70 had incomplete data). 81% of those with current alcohol disorders had alcohol abuse or dependence by QDIS criteria. Patients with current alcohol disorders were younger and less likely to be married than those with no alcohol disorders. Patients with no alcohol disorders had the least psychiatric comorbidity. PCS scores did not differ between the three groups. MCS scores were adjusted for age, marital status, education, physical and psychiatric comorbidities, patients with current alcohol disorders had the lowest scores (MCS= 43.5), while patients with former alcohol disorders (MCS= 46.3) and patients with no alcohol disorders had higher scores (MCS= 46.7) were similar, overall p=0.0001, p<0.05 between abstinent and current disorders, p<0.001 between current and no disorders.

Conclusions: Patients with alcohol disorders have physical function similar to that of patients without alcohol disorders. However, patients with current alcohol disorders have poorer mental health status than do patients without alcohol disorders. Patients with former alcohol disorders have mental health status comparable to that of patients without alcohol disorders when the effect of other psychiatric comorbidities is considered, which suggests that mental health status improves with abstinence. More than a third of ambulatory VA patients with a history of alcohol disorders achieved abstinence.

Impact: Abstinence from alcohol is associated with better mental health status in primary care patients with alcohol disorders. However, patients with alcohol disorders have other psychiatric comorbidities, which might also respond to mental health treatment and further improve their mental health status. Future work should examine the role of substance abuse treatment in attainment of abstinence for primary care patients with alcohol disorders.

HSR&D Funded: SDR 91006.s

3. Depressed Mood, Income Loss and Unemployment: The Cardia Study

Mary A. Whooley, MD, VA Medical Center and University of California, San Francisco, CA. CI Kiefe, University of Alabama at Birmingham, AL. MA Chesney, University of California, San Francisco, CA. JH Markovitz, University of Alabama at Birmingham, AL. K Matthews, University of Pittsburgh, Pittsburgh, PA. S Hulley, University of California, San Francisco, CA

Objectives: Previous studies have suggested an association between depression and low socioeconomic status, but none have empirically examined the impact of depressed mood on subsequent income or employment. We evaluated whether depressed mood predicts subsequent loss of income or unemployment among young adults enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study.

Methods: In 1985/86, we recruited 5115 adults ages 18-30 years, including roughly equal numbers of African Americans and Whites, men and women, from four cities in the U.S. for the CARDIA study. For this analysis, we included 2334 participants from the 1990/91 exam who were employed full- or part-time and who reported an annual family income of $25,000 or more. We used logistic regression to evaluate self-reported unemployment and annual family income in the ensuing 5 years, comparing participants who had depressed mood (defined as a score of at least 16 on the Center for Epidemiologic Studies Depression Scale (CES-D)) with those who did not have depressed mood in 1990/91.

Results: Of the 2002 participants who completed the 1995/96 exam, 386 (19%) had depressed mood (CES-D >=16) in 1990/91. The proportion of participants who reported an annual income under $25,000 in 1995/96 varied from 6% in those who had fewer than 4 depressive symptoms in 1990/91 (lowest quintile) to 17% in those who had 16 or more depressive symptoms (highest quintile) (p for trend < 0.001). A total of 17% (62/371) of participants with depressed mood (CES-D >=16) and 7% (113/1631) of participants without depressed mood in 1990/91 reported new low income (<$25,000) in 1995/96 [Odds Ratio (OR) 2.7, 95% Confidence Interval (CI), 1.9 – 3.8; p<0.001]. This association remained strong after adjusting for ethnicity, marital status, education, initial income, full- vs. part-time employment, number of persons in household, and current smoking (OR 2.0, 95% CI, 1.4 – 2.8; p<0.001). A total of 33% (118/354) of participants with depressed mood and 21% (335/1581) of participants without depressed mood in 1990/91 reported new unemployment over the ensuing 5 years (OR 1.9, 95% CI, 1.4 – 2.4; p<0.001). This association remained strong after adjusting for potential confounding variables (OR 1.7, 95% CI 1.3 – 2.2; p<0.001).

Conclusions: Depressed mood predicts subsequent income loss and unemployment among working young adults.

Impact: This decline in socioeconomic status is an important outcome in itself and may contribute to the poor health outcomes associated with depression.

HSR&D Funded: Research Career Development Award 97-325.A

4. Mailed Information Improves Knowledge About Early Detection and Treatment of Prostate Cancer

Objectives: To determine the impact of a mailed informational brochure on men’s knowledge and preferences regarding prostate cancer early detection and treatment.

Methods: A randomized controlled trial was conducted comparing a mailed informational brochure to usual care in male veterans aged 50 years and older. Men (n=550) were randomly selected from a list of patients scheduled for appointments at the Minneapolis Veterans Affairs Medical Center primary care clinic. One half of the participants were randomly assigned to receive a pre-tested mailed brochure (Flesh-Kincaid reading grade level of 7.0) 7-10 days prior to their scheduled clinic appointment. All 550 were mailed a validated survey (Flesh-Kincaid grade level-6.4) 7-10 days after the appointment according to a modified Dillman method to assess demographic characteristics, medical history, and knowledge and preferences regarding prostate cancer detection and treatment.

Results: Survey response rate was 70%. The mean age was 71 years, 91% were white, 69% had a high school education or greater, 49% rated their health as fair-poor. As measured by the VISTA, Prostate specific antigen (PSA) testing occurred within the previous year in 47% of men. This did not vary by age or self reported health status. Men randomized to receive the informational brochure were better informed then men in the control group as measured by correct responses to validated questions regarding the natural history of prostate cancer (31.5% vs. 22.9%), the accuracy of PSA testing (54.4% vs. 41.6%) and treatment efficacy (43.4 vs. 26.2) [all p values < 0.05]. More men in the intervention group answered all three of these questions correctly (14%) than men in the control group (6%) [p < 0.05]. Men receiving the informational brochure were more likely to have talked with the physician at the index visit about prostate cancer screening than control patients (21% vs. 16%) and to prefer watchful waiting, if cancer were found (43.5% vs. 34.3%; p=0.08).

Impact: Mailed informational brochures represent an efficient, effective and low cost method to improve the knowledge of male veterans regarding the potential risks and benefits of prostate cancer screening and treatment. Broad based implementation of these results can enhance informed decision making for a large number of veterans and improve prostate diseases health care delivery.

HSR&D Funded: HFP 98-001

5. Duration of Survival for Disseminated Malignant Melanoma: Results of a Meta-Analysis

Objectives: The goal of this exercise was to estimate the survival experience of patients with disseminated malignant (Stage IV) melanoma regardless of treatment received. This is important as multiple treatment options are becoming available for this patient population and an understanding of a baseline survival experience is necessary in order to assess potential advances in therapy.

Methods: Articles (including abstracts) published in the English language medical literature between 1985 and 1999 were identified through an electronic keyword literature search using MEDLINE and PUB-MED as well as the reference lists of review articles. Some literature published prior to 1985 was identified through these searches and included. Median survivals across all data, for the post and pre-1985 periods and for only the larger studies (n>=20) were calculated using a weighting scheme based on sample size and study characteristics. An attempt was also made to estimate frequency of long-term survival to 2, 3, and 5 years in this patient population (also stratified on the study publication time).

Results: A total of 83 studies were identified encompassing 6,322 patients. Overall median survival from diagnosis of Stage IV melanoma was estimated to be 8.1 months (approximate 95% confidence interval [CI], 7.3 to 8.9 months). For the 59 studies published since 1985 (covering 3,715 patients), median survival was 8.9 months (approximate 95% CI, 7.9 to 9.9 months). Prior to 1985, the figure was 5.8 months (approximate 95% CI, 4.5 to 7.1 months). For the 67 studies with at least 20 patients (totaling 6,024 patients), the median survival was 8.1 months (approximate 95% CI, 7.2 to 9.0 months). Long-term survival for the post and pre-1985 periods over 2, 3 and 5 years was estimated to be 13.6%, 9.7%, and 2.3%, respectively, which was consistent across the two time periods.

Conclusions: While the survival experience in Stage IV melanoma patients has improved since 1985, the use of varied approaches to treat this disease has not produced a favorable long-term prognosis.

Impact: This meta-analysis allows comparison of survival results for current and future trials with expected survival based on cumulative findings to date.

David Hsiang-Shan Au, VAPSHCS, Seattle Division, Health Services Research and Development, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, JR Curtis, Division of Pulmonary and Critical Care Medicine, University of Washington, NR Every, VAPSHCS, Seattle Division, Health Services Research and Development, Division of Cardiology, University of Washington, MB McDonell, VAPSHCS, Seattle Division, Health Services Research and Development, SD Fihn, VAPSHCS, Seattle Division, Health Services Research and Development, Division of General Internal Medicine, University of Washington

Objectives: Beta-adrenoceptor agonists (beta-agonists) are commonly used to treat obstructive lung diseases and preliminary studies have suggested they are associated with an increased risk of adverse cardiovascular outcomes. The objective of this study was to examine the association between myocardial ischemic events and inhaled beta-agonist therapy.

Methods: We performed a population-based, nested case-control study using data that were collected as part of the ongoing prospective Ambulatory Care Quality Improvement Project being conducted in the primary care clinics of 7 Veterans Administration (VA) medical centers. We identified 630 cases of unstable angina or acute myocardial infarction for which patients were admitted between the years 1996 and 1999. These cases were then frequency matched to 10,486 controls according to study site and index date. The VA medical centers’ computerized pharmacy databases were used to determine beta-agonist use. Cardiovascular risk factors were assessed prior to the index date by patient self-report, ICD-9 codes, and computerized laboratory and pharmacy information. For cases, the index date was defined as the date of admission for unstable angina or myocardial infarction. The control patients were assigned a randomly selected case index date.

Results: In comparison to subjects who had not filled a beta-agonist prescription during the 90 days prior to their index date, subjects who had filled a beta-agonist prescription had an increased risk of myocardial ischemia. The increased risk of myocardial ischemia persisted after adjusting for age, history of cardiovascular disease and cardiovascular risk factors including hypertension, diabetes and smoking history. There was a dose-response relationship with adjusted odds ratios of 1.63 for 1 MDI canister (95% CI 0.98, 2.75), 1.78 for 2 –3 MDI canisters (95% CI 1.17, 2.68), and 2.18 for 4 or more MDI canisters (95% CI 1.40, 3.41). After stratifying for receipt of a beta-blocker medication, the adjusted odds ratio among subjects who did not receive a beta-blocker was 2.40 for 1 canister (95% CI 0.99, 5.81), 2.88 for 2 –3 canisters (95% CI 1.46, 5.69), and 4.91 for 4 or more canisters (95% CI 2.68, 8.99). Subjects who had used both beta-blockers and beta-agonists had similar increased risk of myocardial infarction or unstable angina compared to those using beta-blockers alone.

Conclusions: Patients prescribed beta-agonist inhalers were at increased risk of myocardial infarction or unstable angina and that a greater number of canisters were associated with a greater risk.

Impact: Our study suggests that clinicians should exercise caution when prescribing beta-agonists to patients at risk for cardiovascular disease and that myocardial ischemia should be considered as a potential cause of dyspnea among patients with obstructive lung disease. In addition, clinicians should consider limiting beta-agonist use to doses with demonstrated efficacy and encourage patients to not overuse this medication. For those patients who require beta-agonists, concomitant therapy with beta-blockers should be considered if clinically warranted.

Objectives: Abdominal pain is a common complaint with associated disorders ranging from benign self-limited conditions to serious ones requiring immediate hospitalization. However, few explicit process-of-care criteria are available for rapid identification and evaluation of patients at risk for serious abdominal pathology. Our purpose was to identify risk factors for hospitalization of patients seeking care for abdominal pain, in order to guide triage processes for the timing and intensity of their initial management.

Methods: Using an evidence-based modified Delphi process, a 9-member multidisciplinary physician panel identified clinical factors that may be associated with increased risk for serious abdominal pathology. VA ambulatory care triage nurses prospectively assessed the presence of these risk factors in patients seeking care for abdominal pain. All hospitalizations within 7 days were identified. Odds ratios [OR] and 95% confidence intervals [CI] were determined for risk factors present in more than 5 patients. Logistic regression was performed using as predictors risk factors associated with hospitalization at p<.10.

Conclusions: Ambulatory patients seeking care for abdominal pain were classified into 3 risk strata for hospitalization. A succinct set of history and physical examination findings that are available to a triage nurse, identify patients in the highest risk strata.

Impact: A 2-step triage process was developed in which independent predictors of hospitalization were assessed as the first step, and, for patients without these independent predictors, all other risk factors were assessed as a second step. Adoption of this process achieves brevity in identifying high risk patients, while improving sensitivity in identifying other patients at risk for hospitalization. This may be safer and more efficient than the implicit triage methods that are currently in widespread use.

8. Further Validation of an HIV Symptom Index: Symptoms among Depressed and Non-depressed HIV+ Veterans

Objectives: The use of highly active antiretroviral therapy (HAART) among 70-80% of HIV+ patients in care is believed to have substantially changed the prevalence of common symptoms. Physical symptoms associated with treatment (nausea, bloating, and diarrhea) may have increased. Affective symptoms (sadness, anxiety, and even frank depression) are believed to have decreased. We sought to further validate a new index of HIV symptoms in a cohort of HIV+ Veterans exposed to HAART by determining: (1) the prevalence of symptoms (including bothersome symptoms) and frank depression; (2) the prevalence of physical and affective symptoms among depressed and non-depressed patients; and (3) whether symptom prevalence and bother are associated with health-related quality of life (HRQOL).

Methods: We used baseline data from the Veterans with HIV/AIDS Cohort Study (VACS), which is enrolling patients from Houston, Cleveland, and Manhattan VA HIV clinics. Patients fill out a survey that included a symptom index of 20 common HIV symptoms (e.g. fatigue, fever, cough, nausea, bloating, sadness, diarrhea, difficulty sleeping, muscle aches, sexual problems, anxiety, weight loss, and trouble remembering). Depression is assessed using the CESD-10 and HRQOL is assessed using the SF-12. We use Chi-square analyses to test for significant differences for each symptom between depressed and non-depressed HIV patients, and to assess differences between symptoms self-reported to be particularly bothersome. Linear regression was used to determine whether symptoms are associated with HRQOL.

Conclusions: We find a persistently high prevalence of depression, despite the majority of patients being on effective antiviral therapy. The construct validity of our new HIV symptom index was supported by a strong association between depression (assessed using an independent measure: CESD) and both symptoms and symptom bother. Construct validity was further supported by a strong association between symptom bother and independently measured HRQOL (SF12).

Impact: Depression in HIV remains a common problem in the post HAART era. Both physical and affective symptoms as measured by the HIV symptom index are strongly associated with depression and HRQOL. Future research should examine whether treatment of depression may improve HRQOL by decreasing the burden of symptoms in HIV infection.

9. Treatment of Cholesterol in the Secondary Prevention of Coronary Heart Disease: How well are we doing?

Objectives: Incorporation of new information into clinical practice is notoriously slow. Several large clinical trials have documented the benefits of lipid lowering therapy for patients with coronary heart disease (CHD) and elevated cholesterol, specifically high LDL-cholesterol (LDL-C). The purpose of this study was to determine the extent to which physicians prescribe lipid lowering therapy to CHD patients with high LDL-C and to identify predictors of prescription of lipid therapy.

Methods: This was a retrospective cohort study using VA administrative and clinical databases. The cohort included 13,322 patients from Network 13 who met these entrance criteria during 1994-1996: 1) CHD diagnosis (based on any inpatient ICD-9 code of 410-414 or 429.2; or a coronary revascularization procedure; or at least 2 consecutive prescriptions for nitrates); 2) alive at one year post cohort entry (index) date with at least one primary care visit at a Network facility; 3) no liver disease. Laboratory and pharmacy data were collected through 1998. Lipid therapy was defined as at least one 30-day prescription for any lipid lowering drug (LLD). An indication for LLD was defined as an LDL-C > 130 mg/dl with no subsequent LDL-C < 130 mg/dl, or, in the absence of LDL-C, total cholesterol (TCHOL) > 200 with no subsequent TCHOL < 200. Logistic regression models were generated using backward elimination procedures to identify associations between clinical and demographic factors and LLD prescription among those with an LDL-C indication.

Results: 1190 patients were on a LLD at index date and an additional 713 subsequently received a LLD without a prior LDL-C or TCHOL. Among the remaining 11,419 patients, 31% (N=3533) had an LDL-C and 24% (N=2732) had no LDL-C but had a TCHOL within one year. 48% (N=1711) and 47% (N=1269) of those with an LDL-C or a TCHOL, respectively, had an indication for LLD. 61% (N=1040) of those with an LDL-C indication and 36% (N=453) of those with a TCHOL indication received a LLD. Significant predictors of LLD prescription (odds ratios and 95% confidence intervals), included LDL-C level (1.2, 1.1 to 1.3, per 12 mg/dl increment); pre-index-date use of LLD (2.1, 1.1 to 4.1); pre-index-date LDL-C check (1.8, 1.4 to 2.3); aspirin or ACE inhibitor use (1.4, 1.1 to 1.7); number of pre-index-date cardiac admissions (1.4, 1.2 to 1.8); age (0.92, 0.87 to 0.98, per 5 year increment); number of pre-index-date admissions (0.69, 0.58 to 0.82); and calcium channel blocker use (0.71, 0.54 to 0.93).

Conclusions: This study suggests that only about half of CHD patients are evaluated for high cholesterol and that of those evaluated and found to have an indication for treatment, only about half receive treatment. Our data also identify several factors, such as age, LDL-C level, and co-treatments, that may influence the decision to treat with lipid lowering therapy.

Impact: These results indicate that there may be an opportunity to improve quality of care for CHD patients by improving detection and treatment of high cholesterol.

Objectives: Evidence-based treatment protocols are increasingly being developed to reduce variations in physician practice and improve patient outcomes. Although several studies have been published exploring provider knowledge of and attitudes toward practice guidelines, we are not aware of any corresponding studies of patients. Our goal was to explore patient knowledge of and attitudes toward VA clinical practice guidelines for diabetes.

Methods: Cross-sectional survey data was collected from 60 veterans with Type 2 diabetes. Patients were asked to volunteer for the study while waiting for internal medicine clinic appointments. Participants completed a survey about their demographic characteristics, their knowledge of and attitudes toward VA clinical practice guidelines (CPAs) for diabetes, and questionnaires about their medical information needs (Desire for Medical Information Scale) and decision-making preferences (Locus of Authority in Medical Decision-Making Scale).

Results: Patients had an average age of 62 years. Fifty-three percent had attended college. Diabetes duration ranged from less than one year to 35 years (mean 9.7, SD 8.8 years). The majority (93.3%) received all of their medical care at the VA. Fifty-five percent endorsed knowledge of clinical practice guidelines and 57% percent indicated that their primary care providers had told them about CPAs for diabetes. Fifty-six of the 60 respondents (93.3%) expressed interest in learning more about CPAs. Seventy-three percent rated CPAs for diabetes as being "5- very helpful for their diabetes" on a 5-point Likert-type scale. Patients on average rated the importance of receiving medical information as "very important" (65 out of a possible score of 70). The average response on the Locus of Control for Medical Decision-Making Scale indicated a preference toward shared-decision making.

Conclusions: A majority of veteran patients were aware of what CPAs were and indicated that their physicians had told them about CPAs for diabetes. Patients rated their medical information needs as very important and expressed interest in receiving more information about CPAs for diabetes. Veterans think that CPAs will be helpful for their diabetes. Although the results should be interpreted with caution given the small sample size, future research should explore the impact of systematically providing patients with summaries of clinical practice guidelines. Other research suggests that if patients are aware of a standard of care that physicians should follow in treating their chronic disease, they may be better able to negotiate with their physician and participate in shared-decision making. Knowledge about best practices for the treatment of their disease may similarly enhance self-management.

Impact: These findings support patient education and shared decision-initiatives within the VHA, and underscore the importance of disseminating information about clinical practice guidelines to veteran patients.

Objectives: Many health care organizations today strive to create integrated delivery systems. They expect integration to add value to their organizations, enabling them to provide higher quality care at lower costs while maintaining or improving the health and satisfaction of their patients. But system integration is a complex undertaking. As the VA Upper Midwest Network (VISN 13) began to link its medical centers into an integrated delivery system, network leaders asked the HSR&D Management Decision and Research Center to develop a scorecard to monitor their progress toward system integration. Central to the success of the scorecard was the development of a measure of system integration – the extent to which the system is actually coordinated across operating units. Measures of integration will be made at regular intervals to track change over time.

Methods: System integration was measured through a self-administered staff survey. Survey items reflecting experiences characteristic of a well-integrated health delivery system were developed based on theoretical considerations, previous research, and the integration goals articulated by Network 13. Three separate paper-and-pencil questionnaires were constructed for general staff, managers, and clinical staff. The network-wide sample was stratified by service group and facility. A total of 1490 individuals were selected to participate in the survey. Questionnaires were distributed by interoffice mail and returned in prepaid envelopes to a data entry service. The resulting data were analyzed using exploratory factor analysis to identify tentative dimensions. The psychometric properties of these dimensions were subsequently evaluated using multi-trait analysis.

Results: Responses were received from 73 percent (n=1042) of the 1425 staff members who could be contacted. The factor analysis and multi-trait analysis identified 13 dimensions that could be represented by multi-item scales with high reliability for group comparisons and with good convergent/discriminant validity. Five key scales represented aspects of system integration: (1) leadership; (2) staff cooperation; (3) service cooperation; (4) clinical coordination; and (5) facility-VISN alignment. Four additional integration dimensions were identified based on questions unique to the managers’ version of the instrument: (6) shared vision; (7) quality improvement; (8) single standard of care; and (9) manager alignment. Four dimensions based on questions in all version represented more general attitudes toward work and the quality of system performance: (10) job satisfaction; (11) quality of medical care; (12) service line support; and (13) perceived level of integration.

Conclusions: Methodologically, the integration survey demonstrates that reliable and valid indicators of system integration can be obtained from staff by means of a self-report questionnaire administered by mail. Substantively, survey results confirm that system integration is in its early stages in Network 13.

Impact: Achieving health system integration is a complicated process. Having a valid, reliable measure of system integration provides system leaders with an important management tool. The integration survey offers managers an overall indication of the extent to which the network is integrated, indicates which parts of the system are more integrated than others, and provides information to target particular areas for attention. As the survey is repeated to measure the progress of integration over time, its usefulness will increase further.

Objectives: Over the past five years, 48 VA medical centers joined to create 23 integrated healthcare systems. This multi-year study was designed to analyze these integrated systems to assess their effectiveness and develop management lessons for other systems. This paper examines the structure of the integrated systems, the relationship between structural elements and cultural integration and perceived impact of integration, and the effects of facility integration on system performance.

Methods: Analyses of structural elements, cultural integration and perceived impact of integration were based on cross-sectional comparisons among integrating systems. Data were drawn from surveys of system directors (91% response rate) and managers in the integrated systems (66% response rate). Structural variables included: 1) pre-integration dominance of one facility, 2) physical location of system managers, 3) proportion of services integrated across the system, 4) proportion of services with policies aligned across the system. Cultural integration was measured by staff identification with the system. Perceived impact was measured on four dimensions: access, quality of care, resource availability, and support from other services. Analysis of variance and regression analyses were performed to test differences between groups and to model the interaction of structural variables. Analyses of effectiveness were based on a multiple time-series design with matched comparison groups of non-integrating hospitals. Data were drawn from national VA administrative and patient satisfaction databases. Performance was measured by multiple indicators in four domains: 1) system efficiency, 2) redirection of resources from administrative to clinical care, 3) veteran access to care, 4) single standard of care. Analyses were repeated for three subsets of systems: 1) systems approved for integration before FY98, 2) older systems, approved for integration before FY97, 3) operationally-integrated systems, with policies aligned across campuses in 80% or more services. T-tests were used test pre-post differences and differences between integration and comparison groups.

Results: Managers were significantly more likely to report higher system identification and higher perceived impact of integration if: 1) their policies were the same across campuses, 2) they worked in older integrated systems, 3) system managers were located together in a central headquarters. On measures of system performance, integrated systems improved significantly after integration only on efficiency (FTEE/1000 units of workload) and fewer patient satisfaction problems with access. They showed significantly greater improvement than non-integrating comparisons only on efficiency. On other measures, integrated systems remained level or increased slightly. Older and operationally integrated systems did not show better performance than all integrated systems.

Conclusions: System age, a central headquarters and operational integration appear to reflect maturity and decisiveness in creating an integrated system that reach front-line staff and clinical operations, and translate to greater system identification and perceived impact. However the objective effects of integration appear modest. Beyond improvements in efficiency, which are important, facility integration has limited effects on system performance, at least on nationally available measures.

Impact: The second-phase report will be distributed to all VISNs and medical centers to inform their efforts in integrating services and facilities, and more broadly creating integrated delivery systems. Study investigators have presented their findings in VHA systems beginning the integration process.

Objectives: Improving the quality of nursing home care is increasingly important. Yet little is known regarding why some nursing homes are better able to deliver quality care. Organizational culture, the values, beliefs, and norms of an organization that shape its behavior may be critical. We investigated whether VA nursing homes in which management emphasize teamwork (group culture) and innovation (developmental culture) are associated with continuous quality improvement implementation. We also determined whether quality improvement implementation is associated with employee satisfaction, adoption of clinical practice guidelines and improved patient outcomes as measured by a lower risk of pressure ulcer development.

Methods: We surveyed clinical employees (nurses, physicians, aides and ancillary staff) at 35 VA nursing homes. Nursing home culture was described using the questionnaire developed by Zammuto and Krakower that rates each organization on the extent to which it represents a group, developmental, hierarchical, and rational culture. Quality improvement implementation was captured with a 42-item questionnaire that operationalized the Baldrige Award Criteria. Both instruments have been widely used in VA. Employee satisfaction was measured with a single question on a 5-point Likert scale. Level of adoption of the AHCPR pressure ulcer prevention guideline was measured as the proportion of a nursing home’s staff reporting its use. We used the Patient Assessment File and a previously developed risk-adjustment model to identify pressure ulcer-free residents of these 35 homes during the 12 months ending April, 1999, calculate patient’s probability of developing a new ulcer, and determine whether they had actually developed a new ulcer. Analyses were performed with ordinary least squares regression.

Results: Completed surveys were obtained from 1054 nursing home employees (60% response rate). While individual nursing homes differed considerably in their culture, they were seen as having predominantly a group and hierarchical culture; scores for a developmental culture that values innovation were lowest. Significant differences (p<.001) were seen among nursing homes in their degree of quality improvement implementation with scores ranging from 2.98 to 4.08 (1 to 5 scale). Nursing homes with higher group and developmental culture scores had a higher degree of quality improvement implementation (p<.001). Nursing homes with greater quality improvement implementation had higher employee satisfaction (p<.001) and more adoption of the pressure ulcer prevention guideline (p<.001). Additionally, there was a suggested association with improved outcomes: patients at homes with more quality improvement implementation were at lower risk-adjusted risk of pressure ulcer development (p=0.12).

Conclusions: VA nursing homes that promote teamwork and innovation among their staff have a higher degree of quality improvement implementation. The use of quality improvement is associated with desirable events including guideline adoption, employee satisfaction, and improved patient outcomes.

Impact: These results suggest that developing interventions which promote the implementation of continuous quality improvement in VA nursing homes will likely result in improved quality of care. However, such interventions may only succeed in nursing homes in which management has created a culture that encourages flexible and team-oriented approaches to problem solving. Other strategies for improving care may be required in homes without such a culture.

Objectives: Veterans Affairs’ (VA) leadership has encouraged the implementation of a variety of new organizational structures. One of the most widely-adopted innovations has been the service line (SL). SLs involve reorganization of staff and processes based on the type of care provided (e.g, primary care, mental health) as opposed to the type of health care provider (e.g., physicians, nurses). This study examined the effects of primary care service lines (PCSLs) on one important measure of quality, patient satisfaction.

Methods: A survey of 143 VA facility directors provided data regarding the presence of a facility PCSL, the date it had been established, and how it was structured. PCSLs were categorized as young or old, based on how long they had been functioning prior to the 1998 national VA patient satisfaction survey. PCSLs’ structures were categorized as: minimal restructuring, called task force (TF); moderate restructuring, called team (T); and extensive restructuring into a separate division (D). Some facilities’ structures did not have consistent authority structures regarding different disciplines and were coded as "not classifiable." Scores from the 1997 and 1998 national surveys conducted by the VA National Performance Data Feedback Center were used to measure patient satisfaction with eight specific dimensions of ambulatory care. Regression analyses controlling for facility and patient characteristics were used to examine the effect of PCSLs on satisfaction trends. First we tested the basic hypothesis that having a PCSL of any type would be associated with improvement in patient satisfaction. We then examined whether taking type and age of the PCSL into account improved the ability to predict patient satisfaction trends in general, and whether certain types of SLs were associated with more favorable trends in patient satisfaction in particular.

Results: The simple presence of a SL was not significantly related to satisfaction trends. When age and developmental level were taken into account, however, SL characteristics significantly improved the amount of variance accounted for on three dimensions: preferences, visit coordination and overall coordination. Significant negative effects were observed regarding: (a) old "not classifiable" and access, preferences, patient education, visit coordination and overall coordination; and (b) young teams and overall coordination. Significant positive effects were observed regarding: (a) divisional structure -- both young and old -- and preferences; (b) old divisional structure and courtesy; (c) old teams and courtesy; and (d) old task forces and continuity of care.

Conclusions: Younger SLs were associated with more negative trends in satisfaction than older SLs. More positive trends were observed with divisions than other SL structures. SLs having "not classifiable" structures demonstrated predominantly negative trends, especially when these structures were long-standing.

Impact: Implementation of SLs involving a task force or team management model may be associated with modest declines in patient satisfaction. However, satisfaction levels are likely to recover as the SL becomes established. Division-type SLs do not manifest this initial decline in satisfaction. Young mixed (unclassifiable) SLs, had negative relationships with satisfaction, but did not bounce back with age, as old unclassifiable SLs were most strongly associated with lower satisfaction than any other SL structure.

Objectives: Service lines change the structure of health care provision from one organized by type of care provider (e.g. doctors, nurses), to one organized around the type of care provided (e.g. primary care, mental health). Many Veterans Affairs (VA) health care facilities have implemented primary care-focused service lines (PCSLs) to improve the quality of patient care and reduce resource utilization. This study determined whether implementation of PCSLs in VA Medical Centers has led to improvements in patient outcomes.

Methods: Information gathered from 143 VA facility allowed us to classify PCSLs by: i) their duration, "young" < 32 months, "old" > 32 months; and ii) by the degree of restructuring that had taken place. Five degrees of restructuring were distinguished: no PCSL; minimal, called a task force (TF); moderate, a team (T); well developed, a division (D), and not classifiable (NC). Nine patient-related outcomes were selected for evaluating the performance of PCSLs: primary care enrollment, acute bed day rates, proportion users with at least one hospitalization, discharge rates, multi-stay rates, ambulatory care sensitive (ACS) hospitalization rates, specialty visit rates, urgent care visits per total visits, and urgent care visits per user. Regression analysis controlling for facility and patient characteristics, and heteroskedasticity, was used to determine the effect of PCSLs, presence and classification, on the improvement in these outcomes from 1997 to 1998.

Results: The presence and characteristics of PCSLs had no effect on outcomes of: acute bed day rates, proportion of users with 1 or more hospitalizations, and multi-stay rates. The presence of any PCSL had a significant, detrimental, effect on urgent care visits per total visits and urgent care visit rates. Facilities with old-T PCSLs had a significant positive effect on enrollment in primary care. Finally, the following negative significant effects of categories of PCSLs were also found: i) young-TF on discharge rates; ii) young-TF, young-D and young-NC on ACS hospitalization rates; iii) old-NC on specialty care visit rates; and iv) young-T and young-D on urgent care visits per total visits.

Conclusions: Although all of our measures of VA patient outcomes improved between 1997 and 1998, the presence of any PCSL did not lead to a larger improvement in outcomes, and reduced improvements in urgent care rates. In addition, younger PCSLs specifically were associated with significantly less improvement in several outcomes. PCSLs may lead to an initial period of disruption that limits an organization's ability to achieve its goals. Furthermore, established PCSLs were no better than other forms of organizational structure in achieving stated goals.

Impact: VA medical facilities have made dramatic advances towards system goals, irrespective of the specific type of organizational structure of health care delivery that individual facilities have adopted. However, managers must realize that structural changes, such as implementation of service lines, may be initially disruptive, and may lead to a short run loss in ability to attain goals. Organizational changes should not be undertaken unless there is good reason to believe that the proposed change will lead to - at least - offsetting improvements in the future.

Objectives: Health care organizations are under pressure to demonstrate the quality of their services. Therefore, they are increasingly reporting their performance on quality indicators-- quantitative measures of access, utilization, care processes, and outcomes. They are also attempting to change providers' practice patterns by providing feedback about indicator performance. However, studies report mixed results on the impact of feedback on provider behavior. Feedback seems to be more effective when providers believe quality indicators to be clinically meaningful and within their "sphere of influence." We examined mental health providers (MHPs) perceptions of quality improvement (QI) efforts for mental health services. We collected and analyzed data from 5 focus groups of front-line MHPs in 3 VAMCs to better delineate providers' perceptions of QI efforts, quality indicators, and barriers to an effective monitoring process.

Methods: Each focus group had 10-13 MHPs and included psychologists, psychiatrists, social workers, and nurses (total N=58). A consultant facilitated the groups, using a semi-structured topic outline that elicited participant views on what constituted "quality" services, perceptions of QI efforts, familiarity with indicators, experiences with feedback, priorities for monitoring, and attitudes about accepting incentives/risk for indicator performance. Focus groups lasted 90 minutes and were audiotaped. A research associate took notes during each session and checked transcripts for accuracy. Six investigators, from different professional backgrounds, independently reviewed 2 to 5 of the transcripts. A consensus meeting was held in which important group themes were identified and enumerated.

Results: MHPs expressed a strong belief that front-line providers should be involved in the development and implementation of indicators to ensure that they were germane to local practices, providers, and patients. They expressed a need for expert consultation and for education about mandated monitors. MHPs perceived all domains of indicators, including access, utilization, care processes, and outcome monitors, to have value but had difficulty prioritizing them. They felt that emphasis on only a few indicators or domains might give a distorted view of the quality of services. Although MHPs believed that indicator monitoring might be extremely valuable, they perceive many barriers to implementing meaningful feedback processes. Concerns about data quality included missing data, timing of data collection, skewed samples, distorting effects of the compensation system on patient perceptions of care, "gaming," and lack of adjustment in cross-facility comparisons. MHPs were concerned that data collection decreased patient care time and that workgroup feedback could be problematic due to personnel issues.

Conclusions: Front-line MHPs believe that quality monitoring and feedback is valuable but only IF: front line staff is involved in developing, implementing, and interpreting indicators, expert consultation is available to assist in these efforts, data quality is improved, adequate systems for data collection exist, and there is good communication and leadership support.

Impact: This study provides preliminary data on MHPs' perceptions of quality indicators and suggests ways monitoring and feedback might be made more meaningful. A nationwide survey of MHPs perceptions of indicators is planned for Spring 2000.

HSR&D Funded: IIR98-102

17. The Quality of Care for Depressive and Anxiety Disorders in the United States

Objectives: Depressive and anxiety disorders are prevalent conditions that cause substantial morbidity. While efficacious treatments exist, little is known about quality of care for these disorders nationally. This study estimates the rate of appropriate treatment among the United States population with depressive and anxiety disorders, and examines the effect of medical insurance, provider type, and individual characteristics on use of appropriate care.

Methods: Data were obtained using a cross-sectional telephone survey conducted during 1997 and 1998. We identified, from a national sample, 1641 adults with a probable 12-month depressive or anxiety disorder by brief diagnostic interview. We estimated visits to general medical providers and mental health specialists, and use of appropriate psychotropic medication or counseling. We examined the effect of individual characteristics, provider type, and medical insurance type on use of appropriate care using multivariate regression models.

Results: During the past year, 82% of adults with a probable depressive or anxiety disorder saw a healthcare provider, and most visits were in primary care. While 19% had seen a specialist, only 2% saw a specialist without seeing a primary care provider. Within adults with a probable disorder, 21% received appropriate medication and 18% received appropriate counseling. In all, 31% used some appropriate treatment (95% Confidence Interval, 28 - 34%). Individuals visiting primary care providers had significantly lower rates of appropriate treatment than individuals visiting mental health specialists (21% versus 65%, p<.001). Rates of appropriate treatment were significantly lower for men, African Americans, the less educated, and adults under 30 or over 59 years old. Insurance status and income did not have unique effects on use of appropriate care.

Conclusions: The majority of adults in the U.S. with a probable depressive or anxiety disorder receive no appropriate care for their disorder. While this holds across diverse groups, rates of appropriate care are lower in certain demographic subgroups. These findings emphasize the importance of public education, interventions that increase access to effective care, and targeting subgroups at particularly high risk for poor care.

Impact: Public and patient education efforts are needed to increase the extent to which people value treatment for common psychiatric disorders and seek out appropriate care. Quality improvement efforts should focus on strategies that bring effective treatments to people – whether through improving practice infrastructure or implementing outreach programs. Clinical research has made substantial progress in establishing efficacious treatments, and progress must now proceed on dissemination to the public, especially for vulnerable sub-populations.

Objectives: Schizophrenia is a devastating and costly illness and is the second leading cause of hospitalizations within the Veterans' Health System. Although there are pharmacologic treatments which substantially ameliorate the symptoms of this illness, much community treatment falls short of evidence-based guidelines. The Schizophrenia Patient Outcomes Research Team (PORT) recommends conventional antipsychotic doses between 300 and 1,000 chlorpromazine (CPZ) equivalents per day for acute exacerbations of schizophrenia. Doses less than 300 mg per day are often not sufficient to decrease psychotic symptoms; whereas, doses over 1000 CPZ equivalents provide no additional benefit and are likely to cause more side effects. In this study, we examine whether antipsychotic doses prescribed between 1991-1995 for a large cohort of severely ill schizophrenic veterans conformed to the Schizophrenia Patient Outcomes Research Team (PORT) recommendations. We also examine the relationship between guideline concordant dosing and medication side effects, patient compliance, and psychotic symptoms.

Methods: A cohort of 1071 veterans with schizophrenia on oral antipsychotic medications were enrolled in a study of enhanced programming or standard care between January 9, 1991 and December 19, 1995. Patients were treated at 14 VAMCs and had had either 150 or more days of hospitalization or 5 or more admissions in the year prior to enrollment. At enrollment, clinicians reported patients' current medications and doses, assessed both current compliance and compliance over the last year, and completed a 19-item Brief Psychiatric Rating Scale (BPRS). Patients reported side effects from medications. We describe conformance with PORT antipsychotic dose recommendations and the relationship between doses and side effects, compliance, and psychotic symptoms.

Results: Slightly less than half of patients (49%) on conventional antipsychotics were within the PORT recommended ranges for acute exacerbations. Twenty-four percent were receiving doses below this range and 27% were receiving doses above this range. Of patients receiving less than recommended doses, 42% had BPRS scores >20 and 16% had BPRS scores >30 (BPRS items had anchors of 0-6). Patients reported more side effects with increasing doses of antipsychotic medication (Wald chi-square 3.96, p<.05) but there was no association between dose and compliance ratings (Wald chi-square =2.53, P>0.1). In this cross-sectional study, higher levels of symptoms were associated with higher doses of antipsychotic medication (F=22.04, p<.001).

Conclusions: There was poor adherence to PORT guidelines for antipsychotic doses in this cohort of severely ill schizophrenic patients. A significant minority of patients was receiving lower than recommended doses despite continued psychotic symptomatology. Many other patients were prescribed antipsychotic doses greater than 1,000 mg CPZ equivalents despite the lack of evidence for increased efficacy with high doses. Not surprisingly, clinicians were more likely to use high doses in symptomatic patients despite doubtful efficacy and increased side effects.

Impact: The finding of poor adherence to PORT guidelines for antipsychotic treatment in this severely ill cohort of veterans is of concern and presents clear targets for quality improvement activities. Many patients might benefit from changes in their antipsychotic doses or treatment with atypical neuroleptics.

Objectives: Schizophrenia is a chronic, disabling disorder that occurs in about 1% of the population. Most treatment for schizophrenia is publicly funded, and the VHA is a major provider. Effective treatments include antipsychotic medications. When appropriately used, these medications result in substantial improvement in symptoms, quality of life, and functioning. However, the care provided to patients with schizophrenia is frequently of poor quality. Outcomes are much worse than in projects providing state-of-the-art care, and recent studies have found that more than a third of patients receive inappropriate medication management, and over half do not receive needed psychosocial care. However, very little is known about which organizational, provider, and patient factors are associated with poor quality care. In designing quality improvement interventions, it would be helpful to understand which patients are at highest risk for poor care and why care for this disorder is often of poor quality. We study the extent to which patient, provider and treatment factors are associated with poor quality care at two large mental health clinics.

Methods: We randomly sampled 224 patient in treatment for schizophrenia at one VA mental health clinic and one non-VA public mental health clinic. Appropriateness of medication management was evaluated using an established method, and based on data from patient interviews and medical record abstractions. Multivariate regression was used to study the effect of patient and treatment factors on treatment quality, controlling for provider. Factors examined included number of prior hospitalizations, race, gender, age, compliance with treatment recommendations, knowledge regarding treatment, insight, use of illicit substances, family involvement in care, frequency of treatment visits, and social functioning.

Results: Provider, patient, and treatment factors were each associated with variation in the provision of poor quality care. The two clinics differed significantly in the proportion of patients receiving poor quality care (44% vs. 31%, p=0.04). There was a trend towards physicians being more likely to provide poor quality care if they had fewer patients with schizophrenia in their practice (r=0.60, p=0.06). Risk for poor care was greater in patients with more prior hospitalizations (odds ratio[OR]=1.05 per hospitalization, p=0.05), older age (OR=1.6 per decade, p=0.04), and poor compliance (OR=2.8, p=0.02). There were trends towards poor management of symptoms in men and substance abusers, and poor management of side-effects in Black patients. Provision of poor quality care was significantly associated with failure to document symptoms and side-effects in the medical record.

Conclusions: Patients, providers, and treatment organizations are all reasonable targets for interventions to improve the quality of care for schizophrenia. These interventions should attend to the need for managing challenging clinical situations. Potential areas for emphasis include improving evaluation of symptoms and side-effects, organizational changes (such provider profiling), and increasing access to interventions that improve compliance (such as family and patient education).

Impact: Quality improvement interventions in schizophrenia should target challenging clinical situations and consider a multifaceted approach that includes change at the organizational, provider and patient levels.

Objectives: To assess concordance of post-traumatic stress disorder (PTSD) treatment practices in VISN 21 with emerging guidelines, and to provide baseline data for assessing the impact of VISN 21's Mental Illness Research, Education and Clinical Center on processes of care for veterans with PTSD. Although the VA has not established overall guidelines for PTSD, draft guidelines developed by the International Society for Traumatic Stress Studies, Journal of Clinical Psychiatry, and VA guidelines for comorbid PTSD and depression are indicators of an emerging consensus on best practices.

Methods: Questionnaires assessing treatment practices were sent to all clinicians (n = 69) in VISN 21 who either worked in PTSD specialty programs or were nominated by peers as PTSD experts. Responses were received from 57 clinicians (83%).

Results: Prescription practices are generally consistent with practice guidelines. SSRI's are the drugs of choice for intrusive and avoidant symptoms, Trazadone or Nefazadone are the primary drugs used for insomnia, and either SSRI's or anticonvulsants are typically used to treat hyperarousal. Provision of psychoeducation and psychosocial symptom management is generally consistent with guidelines, with over 80% of clinicians providing such treatments to at least 70% of their patients. Clinicians do trauma-focused work primarily addressing issues of guilt and shame with roughly half their patients, mostly in inpatient settings. Only 25% of clinicians (mostly psychologists) regularly use repeated exposure. This is a substantial discrepancy from practice guidelines that recommend exposure therapy as a first-line treatment. Roughly 90% of clinicians routinely assess for comorbid depression or substance abuse and 75% routinely provide treatment or referral for these common comorbid conditions.

Conclusions: Although there is room for improvement, current treatment practices in VISN 21 are fairly concordant with emerging guidelines for medication management, psychosocial approaches to symptom management, and treatment of comorbid conditions. The greatest discrepancy between current VA practice and emerging guidelines is the limited use of exposure therapy. Future research should assess to what extent this discrepancy is due to patient or clinician preferences, deficits in clinician training, or VA patients characteristics that may make exposure less appropriate (e.g., level of distress, chronicity, lack of external supports, combat vs. other traumatic events).

Impact: These data identify areas of concordance and non-concordance between current VISN 21 PTSD treatment practices and emerging practice guidelines. These results can inform priorities for MIRECC education efforts and provide a baseline for evaluating the MIRECC's impact on processes of PTSD care. Further research is needed to explain the discrepancy between guidelines and current practices for exposure therapy. Clinicians may need more training in exposure that could be addressed in MIRECC education efforts. There may also be a need for further research on indications and contraindications for exposure among veterans with PTSD that can inform VA-specific guidelines for exposure therapy.

21. Adherence to the PORT Study Prediction Rule and Its Impact on Outcomes and Resource Utilization

Cuc H. Quach, Pharm.D., VA San Diego Healthcare System, San Diego , CA, ST Johns, VA San Diego Healthcare System, S Stolley, VA San Diego Healthcare System, LA Lenert, VA San Diego Healthcare System and University of California, San Diego, E Ortiz, VA San Diego Healthcare System and University of California, San Diego

Objectives: Triage decisions in the management of community-acquired pneumonia (CAP) can have significant implications, as treatment setting largely determines costs. Inpatient management, which has been estimated at $7.5 billion per year, represents 89% of the $8.4 billion spent annually on CAP by the United States, while outpatient office management represents 5% of expenditures. Triage decisions regarding the most appropriate treatment setting are not well defined, and hospitalization rates can vary significantly among providers. The Pneumonia Patient Outcomes Research Team (PORT) developed a prediction rule based on 30-day mortality to assist clinicians with decisions about hospitalization. Since its publication, little data has been published on adherence to this rule by healthcare facilities. The objective of this study is to assess adherence to the PORT study prediction rule and its impact on outcomes and resource use in our institution.

Methods: We performed retrospective chart reviews on all patients with CAP who were seen in the Urgent Care or General Medicine clinics at the VA San Diego Healthcare System during 1998. Demographics, treatment setting, comorbid conditions, signs/symptoms of CAP, laboratory and x-ray results, antibiotic use, resolution of CAP, mortality, resource use, and adherence to the PORT study prediction rule were analyzed.

Results: There were 161 patients in the study, including 85 who were initially treated as outpatients and 76 who were initially hospitalized. Of the 85 outpatients, 23 (27%) were in risk classes III-V and should have been considered for hospitalization. Of these, 6 (26%) required subsequent hospitalization compared to 2 (3.2%) of the 62 outpatients in risk classes I-II (p = 0.004). Of the 76 hospitalized patients, 20 (26%) were in risk classes I-II and should have been considered for outpatient treatment. No deaths or rehospitalizations were seen in these 20 patients compared with a 9% mortality (p = 0.32) and 14% rehospitalization rate (p = 0.10) for the 56 inpatients in risk classes III-V (p = 0.32, p = 0.10, respectively). No deaths occurred in any patients in risk classes I-III. Mortality rate was 14% in risk class IV and 33% in risk class V.

Conclusions: Agreement between observed clinical practice and the PORT prediction rule was 73%. Misclassification rates were equal in both directions, resulting in similar hospitalization rates between those observed and those predicted if the rule had been strictly applied. The high failure rate observed in the outpatient treatment of high-risk patients demonstrates an area for quality improvement. It is unclear whether the 26% hospitalization rate for low-risk patients was a result of inappropriate triaging or due to other factors such as compliance or social issues that are not addressed by the prediction rule. This requires further evaluation. Use of the prediction rule may improve triage decisions in high-risk patients. Its impact on low-risk patients remains unclear.

Impact: Clinical judgment frequently deviates from the PORT prediction rule. Further evaluation is warranted to determine the cause of this deviation. Demonstration projects are needed that integrate this and other decision-support tools into clinical practice and evaluate their impact on outcomes.

Conclusions: SISVistA is predictive of VA ICU mortality and is automated.

Impact: Analysis of risk adjusted variation in ICU outcome at all VA hospitals using SISVistA, may allow a focused examination of practices and processes, with identification of "best practice" and subsequent improvement in ICU outcomes.

HSR&D Funded: DEV97-032

23. Physician Unawareness of Urinary Catheters in their Patients: if you don't ask, they won't tell

Objectives: One-quarter of hospitalized patients have an indwelling urethral catheter placed at some time during their stay. Urinary tract infection (UTI) is the most common nosocomial infection, with catheter-related infection accounting for the vast majority of nosocomial UTIs. Catheter-related UTI leads to increased morbidity and healthcare costs. In addition, the majority of patients given indwelling catheters find the catheters uncomfortable and restrictive of their activities of daily living. While urinary catheters are often needed, their use is frequently inappropriate. Studies have found that indwelling catheterization is inappropriate in one-third to one-half of catheterized patient-days. The reasons behind inappropriate urinary catheter use are unclear. We hypothesized that urethral catheters are commonly used inappropriately because physicians are often unaware of their presence. Thus, our aims were to: 1) assess how often attending physicians, medical residents, and medical students know if their own hospitalized patients have an indwelling urinary catheter; and 2) assess whether urinary catheter awareness depends on the appropriateness of indwelling urinary catheter use.

Methods: The physicians and medical students responsible for patients admitted to the medicine wards at three VA medical centers and one university hospital were the subjects of the study. Each provider was given a list with the names of the patients on their service and for each patient was asked to circle "yes" or "no" to the following question: "As of yesterday afternoon, did this patient have an indwelling urethral catheter in place?" Respondents were asked to answer only for patients for whom they had direct responsibility. Respondent's answers were compared to the actual patient situation with the presence or absence of a catheter based on patient examination the afternoon before survey administration. Medical record review was used to assess appropriateness of urethral catheterization.

Results: Of 469 patients, 117 (25%) had indwelling catheters. Catheterization was considered appropriate in 70% of these patients. Among all catheterized patients, 18% of medical students, 22% of interns, 28% of residents, and 35% of attending physicians were unaware that their patients were catheterized. Among inappropriately catheterized patients, 24% of medical students, 31% of interns, 41% of residents, and 51% of attending physicians were unaware that their patients were catheterized. After adjusting for patient age, patient gender, hospital, and level of respondent training, respondents were significantly more likely to be aware of catheters that were appropriate (Odds Ratio = 3.6; 95% CI, 1.6 to 7.8).

Conclusions: Physicians and medical students are commonly unaware that their own patients have indwelling urethral catheters in place. We also found that catheters are often used inappropriately and that these inappropriate catheters are much more often "forgotten" than appropriate ones. Given the morbidity, costs, and patient discomfort associated with indwelling catheters, system-wide interventions aimed at altering the process of indwelling catheterization care seem warranted.

Impact: The best method of limiting catheter-related UTI is to limit inappropriate urethral catheterization. Based on these results, we plan to initiate and evaluate organizational innovations limiting inappropriate urethral catheterization, thereby ultimately improving patient care.

24. Total Joint Replacement Outcomes for Men and Women Treated at VA Hospitals: Results from a National Study

Objectives: To examine relationships between patient sociodemographic, preoperative risk, structure and process characteristics and clinical outcomes of men and women undergoing total knee (TKR) and total hip replacements (THR) at VAMCs.

Methods: Using information collected from the Department of Veterans Affairs (VA) National Surgical Quality Improvement Program (NSQIP), we identified TKR and THR procedures performed at VA facilities between October, 1992 and September, 1997. NSQIP contains data on 62 preoperative risk and demographic characteristics, four process, and 23 outcome variables. We supplemented NSQIP with VA’s Patient Treatment File for readmissions data and facility characteristics data. Files were merged on patient identifiers and procedure date. Any hospitalizations that occurred within one year of the procedure were captured. Outcomes included: postoperative length of stay, morbidity within 30 days (i.e., one or more of 21 complications monitored by the NSQIP), any readmissions that occurred as a result of a complication within one year post surgery. Procedure specific-complications were updated from a list originally developed by Riley and colleagues (1993) with consultation from two orthopedic surgeons who identified additional diagnostic codes and time periods within which they would be considered complications.

Results: Over six years, VA performed 13,889 TKRs ( 3.2% female; 96.8% male) and 10,938 THRs (2.9% female; 97.1% male). Patients were predominately white (83% TKR; 80% THR). The average age was 66.1 years for TKR and 64.8 years for THR, and 67% TKR and 52% THR were married. The primary indication for TKR was osteoarthritis (82%), whereas osteoarthritis (43%), fractures (19%), and diseases of bone and cartilage (12%) were indications for THR. Preoperatively, 20% TKR and 31% THR were smokers, 48% TKR and 39% THR were hypertensive, and 8% TKR and 13% THR were frequent alcohol users. The mean LOS for TKR was 11.2 days (sd=9.2) for women and 9.9 days (sd=8.6) for men; whereas LOS for THR was 12.8 days (sd=14.8) for women and 12.1 days (sd=12.8) for men. Within 30 days of a TKR, 10% of women and 8% of men experienced complications. For THR, 13% of women and 14% of men experienced complications. Logistic regression modeling of 30-day morbidity for TKR identified 9 significant predictors (c-index=0.628) including gender, race, age, hospital size, pulmonary disease, functional status, and total operation time. Modeling of 30-morbidity for THR identified 13 significant predictors including age, functional status, comorbid conditions and pre-operative health status, hospital volume, and whether the case was an emergency (c-index=0.697). Additional analyses will examine gender and surgical indication in more detail. Outcome modeling of readmissions is in process.

Conclusions: Research on TJRs have focused on single outcomes and limited examination of preoperative characteristics. This work examining multiple preoperative characteristics and outcomes indicates that age, comorbid conditions and poor health status are significant predictors of 30-day morbidity. For TKR, gender and race were also significant. For THR, emergency procedures may be indicative of hip fractures.

Impact: This research will provide insight about the relationships between sociodemographic, preoperative risk, structure and process characteristics and clinical outcomes of men and women undergoing TJRs at VAs. This information may be useful for quality improvement efforts in VA and have implications for TJR surgery in non-VA settings.

Objectives: Alzheimer’s disease and other progressive dementias are neurological disorders that may last from 2-20 years during which time the person declines cognitively and functionally. By the terminal stage, the person is typically mute, bedbound, dysphagic and at risk for life threatening intercurrent infections. Ninety percent of the time, pneumonia is the proximal cause of death. Evaluation of the quality of end-of-life care in this population has been limited, in part due to lack of instruments to measure outcomes of care. This study evaluated psychometric properties of three tools to measure outcomes of end-of-life care in individuals suffering from terminal dementia.

Methods: A national survey of family caregivers whose loved one died during the past year was conducted to develop health policy recommendations for end-of-life care. Among the areas responded to by care recipients were three blocks of questions: 1) satisfaction with care (15 items based on the Medicaring questionnaire), 2) physical and emotional symptoms (12 items proposed by the American Geriatrics Society) that occurred during the last 90 days of the care recipient’s life, and 3) comfort during the dying process (15 items based on conditions identified in the literature). Responses were analyzed by item-item correlations and item-total correlations. For each individual block of questions, we examined frequency distributions to delete poorly performing items, performed sequential factor analysis to establish possible subscales, and computed reliability analyses to remove items that were redundant or improved coefficient alpha if deleted.

Results: Based on responses from 156 complete questionnaires representing urban and rural populations in 28 states, three scales were developed. Several items were deleted based on low frequency of responses, high item-item correlations, and positive effect on alpha value. Satisfaction with Care at the End-of-Life in Dementia (SWC-EOLD) consists of 10 items, has a one factor structure, and alpha of .90. Symptom Management at the End-of-Life in Dementia (SM-EOLD) consists of 10 items and has two subscales: physical and psychological symptoms and states. SM-EOLD total alpha is .80; alpha of subscales are .61 and .79. Comfort Assessment in Dying with Dementia (CAD-EOLD) consists of 14 items and four subscales: Physical Distress (alpha .74), Dying Symptoms (alpha .70), Emotional Distress (alpha .82), Well Being (alpha .80). The scale total alpha is .85. There were significant correlations between the three scales and subscales.

Conclusions: The three scales developed and evaluated in this study can be used as outcome measures in studies investigating effectiveness of interventions aimed to improve end-of-life care for individuals with dementia.

Impact: Existing instruments did not specifically address issues of end-of-life care in dementia. As the incidence of advanced dementia increases because of the increased life span of our population, provision of optimal care for this population becomes more and more important. Specific instruments will facilitate development of new approaches to management of this difficult patient population.

Objectives: To define episodes of care that include hospitalizations, and to identify the factors associated with variation in utilization within episodes and in survival.

Methods: An Expert Panel of physicians selected 15 high-volume medical diagnoses and surgical procedures to examine (e.g., coronary artery bypass surgery (CABG), bleeding ulcer). The Expert Panel defined an episode of care for each group using clinical judgment and frequency distributions of preadmission and post-discharge care. Six months of data from the Patient Treatment File and the Outpatient Care File for 1998 pre and post the index hospitalization were examined. Episodes of care were defined to span from 90 days before admission to 6 months after discharge from the index hospitalization. Utilization was divided into: (1) visits to relevant medical or surgical specialists (e.g. for CABG, clinic stops for principal medicine, cardiology, pulmonary, neurology, coumadin, general surgery, cardiac surgery, thoracic surgery, and vascular surgery); (2) relevant tests (e.g. for CABG, EKG, stress test, ECG, echocardiography, pulmonary, cardiac nuclear imaging); (3) behavioral counseling (e.g. for CABG, nutrition, smoking cessation, exercise); (4) post-discharge rehabilitation visits; (5) all readmissions within a specified period following discharge from the index stay (e.g. for CABG,6 weeks); (6) readmissions for specified surgeries or medical diagnoses up to 6 months after discharge from the index stay (e.g. for CABG, PTCA, AMI, and surgical complications, among others); (7) nursing home stays to which the patient was discharged from the index stay or from a readmission defined in (6). Inpatient and one-year survival were the outcomes. The probability of each utilization and survival measure was estimated using mixed model regression analysis, to account for clustering of patients within hospitals, and of hospitals within VISNs. The explanatory variables included comorbidities (e.g., diabetes, hypertension), age, gender, ethnicity, source of admission, discharge destination, marital status, and VISN.

Results: For CABG the most consistent factors associated with utilization and with survival were comorbidities. Admission to the index stay from long-term care was associated with lower probabilities of pre-admission physician visits, counseling, and tests, and with one-year survival. Transfer admissions had lower probabilities of pre-admission and post-discharge physician visits, readmissions, nursing home stays, and both inpatient and one-year survival. Patients discharged to either long-term care or another hospital had lower probabilities of post-discharge physician visits, counseling, and tests. Transfer discharges had higher probabilities of readmissions and nursing home stays. The other explanatory variables were seldom significant.

Conclusions: Clinical factors as well as source of admission and discharge destination are the most important determinants of variation in utilization and survival for episodes of care for CABG. The lower rates of utilization for transfer patients or patients admitted from or discharged to long-term care, might indicate lack of continuity of care. The lack of significance of sociodemographic and geographic variables indicates that VA provides equal access to care for patients along these dimensions.

Impact: Quality assessment for episodes of care is important for capitation reimbursement systems, such as VA's VERA system, and for identifying best practices for specific medical problems.

HSR&D Funded: IIR 95-139.1

27. How Well Do ACGs Characterize the Disease Burden of the VA Population?

Objectives: Adjusted Clinical Groups (ACGs) is a population-based casemix measure that uses diagnostic and demographic information obtained from administrative databases to profile and predict health care resource utilization. The ability of ACGs to produce homogeneous groupings of patients that adequately classify the high percentage of VA patients with multiple comorbid medical and psychiatric problems is unknown. We explored how well different methods of grouping ICD-9-CM codes using the ACG software characterize the disease burden of VA users as well as predict resource utilization (inpatient + outpatient service days).

Methods: We used a 1% random sample of veteran users from the inpatient and outpatient FY'97 files (n=26,095). Dental and phone clinic stops were excluded, and only diagnoses from face-to-face provider encounters were selected. Assignment of ACGs occurs in four steps: 1) ICD-9-CM codes are mapped into Adjusted Diagnostic Group (ADGs); 2) ADGs are grouped into Collapsed ADGs (CADGs); 3) the most frequently occurring combinations of CADGs, known as Major Ambulatory Categories (MACs), form the major branches of the ACG decision tree; and 4) MACs are subdivided into ACGs based on patient's age, gender, and number of ADGs. Each method of diagnostic grouping using ACGs was explored: ADGs, CADGs, MACs, ACGs, and VA-defined MACs (based on the most frequent combinations of CADGs in our sample). We obtained frequencies, utilization means, standard deviations, and coefficients of variation (CVs) per group. Analysis of variance explored how well each set of diagnostic groupings predicted resource utilization.

Results: The most common groupings of ADGs were CADG 6 (chronic medical: stable) (62%), CADG 5 (chronic medical: unstable) (47%), and CADG 2 (acute major) (47%). However, the predefined CADG combinations for the first 23 MACs accounted for only 31% of our sample; 68% were grouped into MAC 24 (the "catch-all" residual category for all other combinations of CADGs). When VA-defined MACs were created, based on the most frequently occurring CADG combinations of VA users, the percent of users in MAC 24 decreased from 68% to 51%. R-squares were 0.05 (MACs), 0.16 (ACGs), and 0.21 (ADGs); for VA-defined MACs, R-square was 0.07. CVs generally exceeded 1.0.

Conclusions: Compared with HMO populations where R-squares for concurrent prediction range from 0.37 to 0.42 for ACGs, and from 0.34 to 0.39 for ADGs, not only were our R-squares lower but our MAC groupings were also more complex, reflecting the higher percentage of multiple comorbidities in the VA population. However, the most frequently occurring combinations of comorbidities, even when redefined based on the VA population, did not predict resource utilization well. Further, the clustering of most patients into a single "catch-all category" also suggests that ACGs do not discriminate well for VA users.

Impact: ACGs are widely used as casemix measures in non-VA settings. As the VA shifts to managed care, effective casemix measures will be critical to successful implementation. Our findings suggest, however, that ACGs need to be modified in order to achieve useful discrimination in a VA population.

Objectives: To demonstrate the potential for calculating population-based and other nonsurvey-based HEDIS measures using current VA databases and evaluate six selected HEDIS measures for validity and reliability within VA. VA is currently creating HEDIS measures and comparisons with the private sector will be inevitable. The lack of positive enrollment data poses unique problems for VA in these comparisons.

Methods: Using a variety of VA administrative data for FY 1996 through 1998, we constructed six HEDIS 3.0 measures: eye exams for people with diabetes, cervical cancer screening, follow-up after hospitalization for mental illness, adults’ access to preventive/ambulatory health services, frequency of selected (cardiac) procedures, and readmission for specified mental health disorders. We used denominators based on VA utilization as proxies for enrollment. We compared rates with numerators based on CPT codes with those based on clinic information. For VISNs 1&2, we supplemented National Patient Care Database and VistA data with Medicare claims and recalculated the measures. We examined inter-VISN scores for individual measures and for correlations among the six measures. We calculated separate rates for patients who used multiple-VISNs to test for lower levels of care.

Results: Inter-VISN variation varied the most for the ambulatory access measure (from 65% to 88% P< .001) and cervical cancer screening (20% to 44%, P< .001). Variation was least for bypass operations (0.7 to 3.9 per thousand, P<.01) and angioplasty (0.8 to 4 per thousand, P<.01). While the cardiac procedure rates were positively correlated with each other (R-squares of 0.21 to 0.39), none of the other measures were correlated with any of the others. The rate of psychiatric follow-up care was not correlated with the rate of psychiatric readmission (R-square of .003). While different denominators altered the HEDIS rates, changing the numerator definitions could raise/lower them by 10% or more. Medicare utilization approximately doubled the eye exam rate and tripled or quadrupled cardiac procedure rates. Patients who received care in more than one VISN in a year had higher average rates of ambulatory visits and cardiac procedures (often the reason for seeking care outside the VISN) and lower rates of readmissions for psychiatric care within 90 days.

Conclusions: Administrative databases are a less costly method for calculating HEDIS performance measures than medical record review, but they can yield widely varying results for VA performance due to differences in coding practices and choice of population denominator. Reliability will improve, however, if encounter databases are supplemented with laboratory or other appropriate data in calculating the measures.

Impact: As VA uses HEDIS-like performance measures to compare patient management across the system or to describe the system for potential enrollees, non-VA utilization (particularly that covered by Medicare) should be taken into account to give an accurate picture of the total health care management of patients. In addition, to have performance measures that are comparable to the private sector, VA must continue its emphasis on improved coding and databases.

HSR&D Funded: IIR MPC 97-0021

29. Examining Variation at Provider, Team and Facility Level for Performance Indicators Related to Diabetes Care

Objectives: The use of profiling to promote improvements in care quality and outcomes depends in part on being able to generate performance profiles that are reliable and on identifying the primary loci of variation in selected measures so that interventions can be effectively targeted. The objectives of this research were: 1) To examine the feasibility of constructing reliable performance profiles of high priority diabetes care processes and intermediate outcomes using computerized VA hospital databases. 2) To evaluate variation in these performance indicators at the provider (PCP), primary care team and facility level.

Methods: Laboratory, pharmacy, and encounter data were obtained from computerized files at seven medical centers comprising one VISN. The study sample consisted of patients who had a prescription for diabetes medications or home glucose monitoring supplies, and at least one outpatient visit during Fiscal Year 1998. Hierarchical regression methods were used to estimate variance components at the facility, team, and PCP level for several selected performance indicators.

Results: Mean glycemic control at VA facilities (HbA1c 7.3%-8.8%) is similar or better than most patient populations currently reported in the literature, although some facilities still have many patients under poor control (patients with a last HbA1c=9.5% ranges from 8%-31% across facilities). Lipid management needs to be improved at all facilities. LDL values are often not available and LDLs over 140mg/dl are relatively common in those patients who have measures (ranging from 18%-30% across facilities). The facility explained the most variation in mean HbA1c and LDL values (22% for both), while PCP and team explained virtually none of the variation in these indicators. The team explained 11% and 6% of the variation in HbA1c obtained and LDL obtained, respectively. The largest amount of variation at the provider level was also associated with obtaining a HbA1c or LDL measurement, varying from 0% to 14% across facilities. However, even in the facility with 14% of the explained variation attributable to the PCP, a provider would need a panel of at least 25 patients for a profile to be considered reliable (reliability = .8).

Conclusions: The development of facility profiles appears quite feasible since there is considerable variation at the facility level for many important diabetes care processes. Conversely, the relatively small amount of variation in HbA1c and LDL values attributable to PCPs suggests that profiles at the provider level will often be unreliable. Moreover, the amount of variation across levels of care differs substantially among indicators. Variation in discrete process measures appears to be greater at the team and provider level, while variation in outcome measures (e.g., mean level of control and proportion under poor control) is found largely at the facility level.

Impact: Profiling efforts and initiatives to improve diabetes care are likely to be most accurate and effective when directed at the facility and team levels. Furthermore, our highest priority for improving diabetes care should be to reduce the number of high risk patients, such as those with an HbA1c > 9.5% or LDL > 140mg/dl.

HSR&D Funded: DIB 98-001

30. Does Getting the History and Physical Right Lead to Better Treatment Decisions? Using Standardized Patients to Link Process to Medical Interventions

Objectives: Measurements of the process of care in the outpatient setting are usually based upon aggregate scores for all aspects of the clinical encounter. However, most clinicians believe that making appropriate recommendations for treatment depends on properly taking a patient's medical history and performing the physical examination. Using standardized patients to control for casemix variation, we evaluated whether correct performance on the history, physical examination, and test ordering phases of a primary care visit predicted correct diagnosis and appropriate treatment recommendations. We also compared data from standardized patient reports to that derived from medical record abstraction.

Methods: We collected data prospectively in the primary care outpatient clinics of two academically-affiliated VA medical centers. From all primary care physicians who consented to participate, excluding interns, twenty (20) were randomly selected. We measured the care that these physicians provided for four medical conditions common in the primary setting. Standardized (actor) patients were trained to present with predefined signs and symptoms of each disease and entered the clinics undetected (8 visits per physician). Explicit scoring criteria were derived from national guidelines and expert panel inputs. Standardized patients rated physician performance for each visit according to these criteria. Medical records for each visit were abstracted using the same quality criteria. We used a multiple regression model that controlled for site and physician training level. The total score for history, physical examination, and test ordering was used to predict the total score for diagnosis and treatment/management.

Results: Standardized patients were successfully used to measure quality of care for five different domains of the clinical encounter. Higher physician scores for the information gathering domains of the encounter were associated with better performance on diagnosis and treatment recommendations (p = 0.11). Study site and level of physician training were statistically significant predictors of performance on diagnosis and treatment (p<0.05). However, chart abstraction quality scores for history taking, physical examination, and test ordering correlated poorly with performance on diagnosis and treatment (p = 0.73). Only site was a statistically significant control factor (p <.0.01).

Conclusions: Quality measurement using standardized patients appears to reliably capture the quality of care for common medical conditions in the outpatient setting and to predict diagnostic accuracy and appropriate treatment for those conditions. However, quality measurements derived from the medical record are not as successful in predicting performance.

Impact: If validated in further studies and analyses, these findings may demonstrate that taking a thorough history and performing a careful physical examination successfully predict the quality of care. Quality improvement interventions could then be specifically designed and targeted to improve these aspects of the clinical encounter.

HSR&D Funded: IIR 95-014.B

31. Measuring Compliance with Preventive Care Guidelines: A Comparison of Standardized Patients, Clinical Vignettes and the Medical Record

Objectives: Increasingly payers and patients are holding providers accountable for the quality of preventive care. Measurements of preventive care, however, typically rely on chart abstraction, which may underreport preventive services. In this study, we evaluate the effectiveness of chart abstraction to measure selected preventive care services and compare these results to reports by standardized patients and responses to clinical vignettes. We also compare chart abstraction to patient self-reports from representative samples of the corresponding patient population.

Methods: We collected primary data prospectively at two VA Medical Centers in the outpatient clinics. Three data collection strategies were used: 1) standardized patients, who served as the gold standard and presented undetected as patients; 2) the medical record generated from that visit; and 3) an identical written case scenario (vignette) to measure physician competence. Twenty physicians were randomly selected among consenting residents and faculty (97% agreed to participate). Preventive care scoring criteria based on national guidelines were developed for seven prevention measures. These were then recorded by a standardized patient, abstracted from the chart or asked of the physician in open-ended clinical vignettes. Physician subjects completed 160 evaluations of standardized patients (8 cases x 20 physicians). We 1) calculated the percentage of visits in which each prevention measure was recorded in the chart; 2) determined the marginal percentile improvement of the standardized patient checklist scores and clinical vignettes over chart abstraction alone; and 3) compared the three methods using an ANOVA model. We also compared chart abstraction scores to patient self-reports from the Veteran's Health Survey, available for the study sites for three prevention items.

Results: Compared to the gold standard of standardized patients, chart abstraction underestimated overall compliance with preventive measures by 16%. Total chart abstraction scores (45.8% ± 14.4%) were lower than scores for both standardized patients (61.7% ± 12.9%) and clinical vignettes (48.3% ± 10.4%). Chart abstraction underestimated physician performance for each of the seven items when compared with standardized patients, and for four items when compared with vignettes. The marginal contribution of standardized patient scores and vignettes to performance as measured by chart abstraction was significant for all seven prevention measures, raising overall prevention scores from 46% to 72%. Finally, actual patients reported more preventive care than standardized patients for two of three measured items.

Conclusions: These data support the view that chart abstraction significantly underreports compliance with preventive care guidelines. In this study, standardized patients and patient self-reports showed that more preventive care is taking place than would be reported if the medical record was used alone. We found that additional information can be obtained be measuring physician competence using clinical vignettes.

Impact: These data indicate that physicians may actually perform more preventive care than they report in the medical record. Benchmarks of individual or institutional performance based solely upon chart abstraction may not accurately reflect the extent of compliance with preventive care guidelines. Alternative strategies of quality measurement, including patient self-report and clinical vignettes, could be used more widely to measure preventive care.

HSR&D Funded: IIR 95-014.A

32. Does Early Cognitive Impairment Have an Impact on Healthcare Utilization in Geriatric Outpatients?

Laura Wray Palumbo, Ph.D., VA Western NY Healthcare System and State University of New York at Buffalo, Buffalo, NY, R Fromme, State University of New York at Buffalo, C Barrick, VA Western NY Healthcare System and State University of New York at Buffalo

Objectives: To examine patterns of healthcare utilization across three groups of geriatric outpatients: those without cognitive impairment, those with unrecognized probable cognitive impairment, and those diagnosed with dementia.

Methods: The charts of all patients referred during the study period to Adult Day Health Care, a VA outpatient tertiary care setting, were reviewed. Healthcare utilization (primary care visits, ER and urgent care visits, additional laboratory and procedure use) for one year prior to enrollment in the Adult Day Health Care Program (ADHC) was examined. The charts of patients younger than 65 or without one year of prior utilization of VA services were excluded. Charts were grouped based on Folstein MMSE cut-off for the patient’s age and education and prior diagnosis of dementia. A total of 120 charts were reviewed. Fifty patients displayed no significant cognitive impairment (Cognitively Intact group = CI); 40 patients displayed cognitive impairment but had not been previously diagnosed with dementia (Probable Cognitive Impairment group = PCI) and 30 patients had been previously diagnosed with dementia (Dementia Diagnosis group = DD). The Chronic Disease Score, an illness severity measure based on pharmacy data, was collected as a covariate. Data concerning demographics, healthcare utilization and physician recognition of cognitive symptoms was also collected. The research assistants extracting information from the charts were kept unaware of the group membership of the patients and the purpose of the study.

Results: Primary Care Providers documented concern about dementia in 10 patients in the PCI group and in 4 patients in the CI group resulting in a 25% recognition rate of probable dementia and a false positive rate of 8%. An overall multivariate test (ANCOVA) was significant (F (4,112) = 7.08; p <.01) indicating that the three patient groups displayed significantly different patterns of healthcare utilization when illness severity was held constant. Follow-up analyses found that the CI group made the most use of primary care services (mean = 41.31) and the DD group used these services least (mean = 17.60). Primary care service use in the PCI group (mean = 39.13) was significantly less than in the CI group. The PCI group used the greatest number of additional procedures (mean = 70.55). The CI group used fewer additional procedures (mean = 39.62) and the DD group used these services least(mean = 21.73).

Conclusions: Patients with early cognitive impairment may not make efficient use of primary care resources that can help to manage their comorbid illness. As a result, we found an large increase in number of laboratory and diagnostic procedures used in their care.

Impact: The relationship between cognitive functioning in the frail elderly and healthcare utilization may have important implications for future resource allocation. Earlier detection of cognitive decline and appropriate support programs could save money and resources, and improve healthcare outcomes and quality of life.

Objectives: To compare cervical cancer screening rates derived from administrative data with those calculated from patient records and survey data. Such screening is important in assessing the delivery of women’s health services.

Methods: We used inpatient and outpatient administrative files from the VA’s National Patient Care Database to calculate the percentage of female veterans aged 21-64 who received one or more Pap tests in FY 1996-1998. For VISNs 1 and 2, we added VistA laboratory data and Medicare claims data and recalculated the screening rates. We compared our results using administrative data to findings from VA survey data and medical record review. We also compared VA rates to rates for cervical cancer screening among women enrolled in managed care organizations and among underserved women in the private sector.

Results: Based on VA administrative data only, 37% of the 99,000 female veterans aged 21-64 (who received VA health services during FY’98) had a Pap test at a VAMC during FY1996-98. Including VistA lab data increased the rate by 6%, but Medicare claims added few additional Pap tests for this population. The External Peer Review Program’s (EPRP) results for FY’98 indicate that 84% of female veterans under age 65 received a Pap test at a VA facility during the 3-year period and another 7% from a private sector provider, based on documentation in the medical records of 3,446 patients selected according to EPRP sampling criteria. When we re-calculated the cervical cancer screening rate for the sample of women who met EPRP criteria, we found a rate of 54% (vs. 84%) using VA administrative data only. VA survey results for FY’98 show a self-reported cervical cancer screening rate of 89% for female veterans under age 65 who have received VA primary care services. The cervical cancer screening rates for women in the private sector are higher than VA rates based on VA administrative data only, but lower than VA self-reported rates and VA rates based on selected patient records that meet EPRP criteria for number of visits, type of clinics, and selected diagnoses.

Conclusions: How a population denominator is defined and which data sources are chosen can yield widely varying results for VA performance measures such as the cervical cancer screening rate. VA may bias its performance measures upward by defining its user population to include only frequent users of primary care services. Private sector providers include all enrolled members or eligible patients in performance measurement. Further research is needed to determine how representative the samples of female veterans are that are selected for medical record review and survey, relative to the population of all female users of VA health services. Incentives are also needed to enhance coding practice and ensure that all VA services are captured as workload.

Impact: Findings from this study have important implications with respect to VA coding practices, workload capture, and billing for VA services, as well as for how VA calculates cervical cancer screening rates and other performance measures.

HSR&D Funded: MPC 97-0021

34. Physician Referral Choices in the Management of Patients with Neurological Conditions

Objectives: With the emergence of managed care and gatekeeping, understanding the preferences of specialists to be involved in patient care and the intentions of primary care physicians (PCPs) to involve specialists in the care of patients is central to concerns about quality of care. We compared neurologists’ preferences and primary care physicians’ intentions regarding specialist involvement in the management of Parkinson’s disease, transient ischemic attack (TIA) and dementia.

Methods: A stratified random sample of family physicians, general internists, and neurologists from the nine states having the highest penetration of managed Medicare was drawn from the AMA Physician Masterfile, ACP-ASIM membership database and AAN membership database. We mailed each physician a 20-minute survey containing three clinical scenarios. Each scenario was followed by options for a PCP to either manage alone, curbside, or refer to a specialist. Practice characteristics, knowledge, and utilization management techniques, including financial incentives, were also assessed.

Results: Overall response rate was 60% with 321, 367, and 299 completed surveys obtained from each database, respectively. Internists’ and family physicians’ intentions to manage without a referral differed from neurologists’ preferences for a PCP to manage without a referral: Parkinson’s disease (54% of internists and 60% of family physicians vs. 10% of neurologists, p<0.001), TIA (63% and 54% vs. 8%, p<0.001) and dementia (80% and 71% vs. 5%, p<0.001). Bivariate analyses of factors influencing choices for specialty involvement revealed that, across all three scenarios, more PCPs in staff model HMOs (35%) intended to curbside than PCPs in all other practice settings (11%) (p’s < 0.001). On bivariate analyses, PCPs who did not know or were unsure of recommended clinical practice for the three scenarios were less likely to manage the patient alone than PCPs with correct knowledge (p’s <0.05). Our multivariate model included physician specialty (general internist versus family physician), practice setting, other practice characteristics, utilization management techniques and physician knowledge. On multivariate analyses, a family physician, given equal physician knowledge, was more likely than a general internist to curbside a specialist for the dementia scenario (p’s<0.05). Further, even after controlling for several practice characteristics, such as workload and neurology availability, PCP’s in a staff model HMO were more likely to curbside than PCPs in any other practice setting (p’s<0.05). In the dementia scenario, profiling a physician quarterly versus yearly increased the probability of a physician managing the patient alone (p<0.05).

Conclusions: Neurologists and PCPs differed greatly in their preferred use of specialty care for selected neurological conditions. Among PCPs, those who knew less were more likely to refer or curbside a specialist, but given equal clinical knowledge, several non-clinical factors were associated with the PCP’s referral choice.

Impact: As long as patients are restricted in their choice of whether to see a specialist, the large differences between PCPs and neurologists in the preferred use of specialty care for three of the most common neurological conditions is a policy concern. Understanding the factors that influence PCP referral choices may enable us to make judgements about the physician referral choices that provide the best patient care.

35.

Assessing Health Care Quality Using the VA Decision Support System (dSs): TheFuture Is Now

Workshop Objective: Attendees will learn to use the VA Decision Support System (dSs) to (a) analyze current care processes, (b) develop a model for assessing quality ofcare, and (c) measure clinical outcomes and cost of care.

Activities: The workshop will include four presentations demonstrating the utility of the Decision Support System (dSs) for addressing quality of care and costs. The workshop faculty, comprising HSR&D investigators and staff of the CIO Implementation and Training Office, will present ongoing research using the dSs. Specific presentations will include:

1) INTRODUCTION AND OVERVIEW OF DSS, presented by Denise M. Hynes, PhD, RN, will provide background and context for the dSs system, including a summary of the available technical and documentation resources.

2) HEMOGLOBIN A1C COMPLIANCE AS A MEASURE OF QUALITY: FUNDAMENTALS OF DSS USE, presented by Roxanne Rusch, MSN, will focus on dSs capabilities for modeling quality of care standards/processes and assessing variance from the model. Data from a multi-hospital study of diabetes management will be presented to demonstrate these fundamental concepts.

3) VA vs. NON-VA HOSPITALIZATION FOR MYOCARDIAL INFARCTION, presented by Paul G. Barnett, PhD, will describe use of dSs to determine the cost of hospital stays for myocardial infarction at four VA medical centers. The presentation will consider data validity, variance among facilities, and comparison with the cost at non-VA hospitals.

4) VA MASTECTOMY CARE: RESEARCH WITH ASSISTANCE FROM dSs SITE TEAMS, presented by Patricia A. Murphy, MS, will focus on technical aspects such as creating a dSs Toolkit and importing dSs data to Excel or a SAS analysis file. Data from an ongoing study will be used to demonstrate how working with dSs site teams to obtain data on a pre-defined cohort can be accomplished. The workshop panel will utilize on-line demonstration, narrative presentation of examples, and handouts. Interaction of presenters and attendees will be encouraged.

Objectives: Many questions in research can be answered best with a multi-site study. Increasing the number of sites, however, adds additional layers of complexity beyond that of a single site trial. This workshop is to help researchers better know what to expect with these more complex studies. Specifically, our objective is: To understand the details involved in the initial conduct of a multi-site trial.

Activities: We will use our experience with the Quality Improvement Trial for Smoking Cessation (QUITS) to highlight the steps involved in the preparation and conduct of a multi-site study. QUITS is a randomized controlled trial of using evidence-based quality improvement to help implement clinical practice guidelines for smoking cessation, involving 20 VA sites throughout the Southwestern US. We will discuss each of the steps involved in detail, including the amount of time and effort necessary, costs, and lessons learned. Specifically, we will cover the following overlapping phases:

1. Writing the proposal.

2. Identifying sites and soliciting participation.

3. Human subjects committee approval.

4. Beginning the study.

5. Maintaining interest and enthusiasm.

Audience participation will be encouraged.

Target Audience: This workshop is intended for people considering or beginning a multi-site trial. The study forming the basis of the discussion uses quality improvement to intervene at the organizational level. While many of the comments will apply to any multi-site trial, it is most representative of other organizational interventions.

Audience Familiarity: The participants should have a very general familiarity with health services research and with interventions at the institutional level.

37. Development of Computer Instruments for Measurement of Patients’ Preferences

Workshop Objectives: The measurement of preferences and utilities for health outcomes is a developing science that often provides crucial information about the risk-to-benefit ratio of medical therapies and their overall cost-effectiveness. In this workshop, we will review key methodological issues in implementation of utility elicitation experiments and demonstrate software designed to help researchers create easy–to-use computer instruments for conducting utility elicitation experiments.

Activities: In the first part of the workshop we will review different methods for measurement of utilities (standard gamble, time trade-off, analog scale, willingness-to-pay) discuss the advantages and disadvantages of each approach, and demonstrate computer implementations of each approach. We will then discuss effects of variations in procedures for administration on measurements and approaches validating computer and traditional instruments.

In the second part of the workshop we will demonstrate how investigators can create computerized utility elicitation instruments using a (free) web site we have developed for this purpose. The site allows a researcher to design an experimental protocol for measurements of preferences online, using only a web browser (Microsoft Explorer). Once the design is complete, the web site generates a set of hypertext markup language files implementing the protocol. These files are then downloaded to the researcher’s computer. The result is a completed "web site" that researchers can use in a stand alone fashion on their computer to conduct preference elicitation interviews, or can post to a web server. Results from preference studies are automatically transmitted either to the researchers email account or to a web accessible database at the end of a session.

Target Audience: Researchers interested in conducting experiments that measure patients’ preferences for health outcomes. Researchers interested in developing decision support tools that use utility measurements in conjunction with decision models.

Audience Familiarity: Participants should bring to the workshop some background familiarity with how preference measurements are used in health services research (e.g., decision analysis, cost-effectiveness analysis, etc.), why measurements are important, and a basic knowledge of decision analysis and utility theory.

Objectives: This workshop will familiarize participants with: Objectives of CBOCs Operation of CBOCs the CBOC Performance Evaluation Project and Methods of Conducting Performance Evaluations of CBOCs using a variety of VA databases.

Activities: This workshop will be divided into two parts: Presentation of methods and findings from the CBOC Performance Evaluation Project. Discussion of how these methods can be employed to evaluate CBOC in the future by Headquarters VISNs VA medical facilities.

Workshop Objectives: Changes to organizational structure and management have become increasingly interesting to health services researchers. Yet the study of such phenomena is difficult, given the lack of control researchers usually have over the implementation of such innovations. Within this workshop, our aim is to generate a discussion of the issues inherent in research evaluating organizational changes, based on our experiences with the service line evaluation project. In this project, we had a unique opportunity to evaluate the effects of implementation because some VHA facilities had implemented the structural change of interest while others had not. We were able to apply multiple methods in this project, both describing the change and analyzing its effects by looking at outcomes, utilization, and patient satisfaction data.

Activities: The workshop will consist of five segments, each led by one of the presenters. We will begin with a discussion of the theoretical underpinnings of the particular organizational change under investigation; discussing why service lines are theorized to improve organizational outcomes. Next, the relationship between our research questions and the data collection procedures we designed will be explored, focusing on the method we developed for collecting reliable data on the extent and type(s) of service line development in VHA facilities. The use of site visits and telephone interviews to collect descriptive data will also be addressed. We will describe the findings these yielded about the numbers, clinical foci, and structural categories of service lines in VHA facilities. Third, we will describe how an expert panel went about defining relevant quality and utilization indicators in order to test the hypothesis that service line structures would yield such improvements. Our findings, with respect to the potential impact of service line structures on quality and utilization outcomes as well as on patient satisfaction, will be reported and discussed in the final two workshop segments. Finally, we plan to engage workshop participants in a discussion of the data collection methods and measures employed, interpretation of our results thus far and the design of future research to further explore our research questions.

Target Audience: Health services researchers who are interested in organizational innovations and analyses of the impact of such innovations, as well as those with a particular interest in service line forms of organization.

Audience Familiarity: It is assumed that participants will have some familiarity with the topic.

Workshop Objectives: Improving patient safety within the VHA is one stated objective of the VA Patient Safety Centers of Inquiry. Only a small percentage of errors in medical care are reported, making data based on numbers of reports in many cases, unreliable and unpredictable. Methods from diverse theoretical background including ethnography, sociology, human factors, and anthropology, are used to investigate safety in non-medical industry and develop and test innovations. Some methodology may be foreign to health services researchers. The objective of the workshop is to create a learning experience where 1) critical concepts in improving safety are introduced 2) methodology used in the Patient Safety Centers of Inquiry are discussed 3) VA focus areas of research on safety are highlighted.

Activities: Workshop objectives will be accomplished using a case based approach to elucidate the strengths and limitations of various research applications in understanding problems critical to improving patient safety. A medical accident case discussion begins the workshop introduction to illuminate common elements found in accident investigation, and the difficulty of moving forward using celebrated cases. A comparison of characteristics of the Aviation Reporting System and the VA adverse event reporting system follows using case information within the database and within the investigation. This comparison will review the typology of adverse events, the expected outcomes for the adverse event database and its potential limitations. Safety problems will then be analyzed applying methodologic approaches from the VA Patient Safety Centers of Inquiry. The use of cognitive work analysis (GAPS, Drs Cook, Patterson and Woods) in understanding how resource constraints, multiple conflicting goals, environmental factors, under time pressure creates the opportunity for accidents which are bridged continuously by healthcare workers creating safety will be reviewed by their application. The application of human factors research in understanding human - computer interface accidents will be discussed. Other approaches to understand and analyze safety will include: use of simulations to maximize team performance and improve understanding of personnel and time limitations at the sharp end; simulation application, focus areas of study, enlisting sharp end creative workgroups, planning and measuring a culture change, research agenda priorities in patient safety.

Objectives: Over the past 15 years numerous studies have documented racial variations in the provision of health care yet the mechanisms underlying these variations remain unclear. The purpose of this workshop is to review issues in past and present racial variation.

Activities: Workshop speakers will review the history of racial variations research as well as different methodological approaches taken by previous studies including the advantages and limitations of using administrative data prospective data and qualitative data.

Target: This workshop is intended for researchers, clinicians, and managers interested in or currently involved with studies of racial variation in the provision of health care.

Familiarity: Familiarity with research methodology would be helpful but is not required.

42. Racial Differences in Satisfaction, Quality of Life and Mortality in Veterans with Diabetes: The Ambulatory Care Quality Improvement Project (ACQUIP)

Objectives: Racial differences in satisfaction, quality of life and mortality have been observed in multiple health care settings but are poorly understood. We analyzed baseline results from diabetic patients enrolled in the Ambulatory Care Quality Improvement Project (ACQUIP) to ascertain whether there were differences between Caucasian (C) and African American (AA) veterans with regard to symptoms, satisfaction, quality of life and mortality at 1 year in this ongoing study.

Methods: As part of the ACQUIP study, a Health Check List, an inventory of current medical problems, and a demographics questionnaire was sent to 38,642 veterans receiving primary care in seven VA General Internal Medicine clinics. Veterans who reported having diabetes (6570) were sent a Seattle Diabetes Questionnaire which was returned by 3450 (53%). The SDQ inquires about the presence of comorbid conditions, type of diabetes, years with diabetes, symptoms, education about diabetes, glucose control and dietary practices. All respondents were also sent the SF-36, a general measure of health-related quality of life and the Seattle Outpatient Satisfaction Questionnaire (SOSQ) which assesses patients’ satisfaction with the humanistic and organizational aspects of medical care.

Results: 74% of respondents classified themselves as C, 18.3% as AA and 7.7% as another racial/ethnic group. There was no difference in length of time receiving care from the VA, although fewer AA received care outside of the VA compared to C (27.3% vs. 34.1%, p<0.05). More AA were single, employed full-time, had incomes <$10,000 and were smokers. Mean duration of diabetes was nonsignificantly greater among AA (10.9 vs. 10.2, p= 0.065). AA patients had higher scores on all SF-36 scales, except for the role-emotional and social functioning scales which were not significantly different from C veterans. Mean satisfaction scores were significantly lower (as measured by the SOSQ humanistic scale) 64.0vs.73.5, p<0.05 respectively). AA patients had more self-reported comorbidities, fewer symptoms related to diabetes and lower satisfaction with diabetes clinic education. The average glucose value +/- SD for the group was 186.5 +/- 66.similar for AA and C. C patients had a significantly higher one year mortality compared to AA (8.7% vs.7.0%; RR = 1.48, 95% CI, 1.02-2.16) after adjustment for age, diabetes type, years of diabetes, marital status, income, comorbidity and education. The risk of mortality in all diabetic patients was 52% higher for patients with an average glucose greater than 250 mg/dl compared with those with a lower value (OR = 1.52, 95% CI = 1.03-2.25).

Conclusions: AA veterans with diabetes had better self-reported quality of life, fewer symptoms of diabetes and lower 1-year mortality compared to C veterans. However, they reported more diabetic comorbidities and were less satisfied with their care and their illness. More information is needed to evaluate if these factors are influenced by quality of care or if they affect diabetes control.

Impact: AA veterans with diabetes had better self-reported quality of life, fewer symptoms of diabetes and lower 1-year mortality compared to C veterans (8.7% vs.7.0%; RR = 1.48, 95% CI, 1.02-2.16). However, AA reported more diabetic comorbidities and were less satisfied with their care and their illness.

HSR&D Funded: SDR 96-002

43. Differences in the Duration of Symptoms and Delay in Presentation for Cardiac Care by Race Age and Site of Care

Objectives: Differences by race, age and site of care exist in the management of coronary artery disease. One hypothesis is that certain groups may have a longer duration of heart-related symptoms and delay seeking care. This delay may influence the decision for an invasive procedure. To assess the duration of symptoms and delay in seeking care for heart disease we surveyed patients evaluated at three VA and one non-VA medical center.

Methods: We prospectively interviewed 924 patients awaiting coronary angiography. We asked patients to report the duration of symptoms and the difference in time between symptom onset and presentation for medical care. We also asked what if any were the reasons for the delay in care. The present report is based on an interim analysis.

Results: Eight hundred thirty five patients (60% > 60 years, 12% AA & 57% non-VA) answered questions regarding duration of symptoms and delay in treatment. Overall 58% of the cohort reported a > 12 month duration of symptoms with 26% reporting 3 months. Seventy percent reported a delay in seeking care of one month or less and 17% reported delaying greater than 6-months. Sixty one percent of patients with age = 60 years reported > 12 months duration of symptoms compared to 52% of patients < 60 years (p=0.013 for trend). There were no differences in symptom duration between African–American and white patients and between VA and non-VA patients. There were no differences in delay in seeking care between patients < 60 years and those = 60 years and between African–American and white patients. Site of care however significantly predicted a delay in treatment with 22% of VA patients delaying greater than 6 months compared to 13% of non-VA patients (p<0.0001 for trend). The most common reason that patients gave for delay of treatment was ignoring symptoms (62%) followed by being unaware they had heart problems (11%). There were no differences in reasons for delay by race or age. By site, non-VA patients were more likely to report being unaware of heart problems compared to VA patients (15% vs. 7%; p=0.012). VA patients more often cited financial reasons for delay than non-VA patients (5% vs. 0.4%; p=0.002).

Conclusions: Older age but not race or site of care is associated with longer duration of symptoms when patients present with symptoms of heart disease. VA patients are more likely to delay presenting for treatment compared to non-VA patients. Significant reasons for this delay appear to be lack of awareness of heart problems among non-VA patients and financial reasons among VA patients. Neither race nor age predicts delay in treatment.

Impact: Efforts to reduce the variation in the use of invasive cardiac procedures in the VA may need to focus on decreasing the delay in patient presentation. The prevailing notion that financial reasons do no play a role in variation of procedure use seen in the VA may not be accurate.

HSR&D Funded: ECV 97-026

44. Gender and Comorbid Psychiatric and Medical Diagnoses Among VA Patients with Alcohol Use Disorders: Association with Substance Use, Psychosocial Functioning, and Service Use

Objectives: The objectives of the present study are three-fold: to examine gender differences in (a) the prevalence of psychiatric and medical comorbidity in veteran patients with alcohol use disorders (AUDs); (b) addiction severity and psychosocial functioning, particularly in the context of psychiatric and medical comorbidity; and (c) type of service sought in relation to psychiatric and medical comorbidity.

Methods: The sample was composed of 10,000 male and 1009 female VA patients with a diagnosis of AUD who obtained treatment at a VA facility in September of 1997. The Addiction Severity Index (5th Edition) was administered at intake to assess problems related to substance use and psychosocial functioning. Information regarding patients' additional diagnoses and service use was also obtained.

Results: Psychiatric comorbidity was high for both male and female patients (62.6% and 72.2%, respectively). A greater proportion of women had a comorbid affective, anxiety, or personality disorder, but no gender difference was found for schizophrenia, after controlling for sociodemographic factors. Women were 1.5 times more likely than men to have a psychiatric comorbidity. Medical comorbidity was also high for both men and women (89% and 85%, respectively), with women having significantly less medical comorbidity (O.R.=.75) than men. We also found significant gender differences in patients' substance use and psychosocial functioning. After controlling for sociodemographic factors and comorbid diagnoses, men had significantly more problems with alcohol use and legal matters, whereas women had more problems with drug use, psychiatric and medical functioning, and their social network. Finally, our results did not show any significant gender differences in the total number of visits to outpatient services including substance abuse, psychiatric, and medical visits. However, men and women significantly differed in use of inpatient services. After controlling for demographics and comorbidity, women were less likely than men to be admitted to a substance abuse inpatient unit (O.R.=.75) but more likely to be admitted to a psychiatric (O.R.=1.45) or medical unit (O.R.=1.38). Furthermore, being a woman and having a medical diagnosis greatly increased the odds of being admitted to a psychiatric inpatient unit to 3.55.

Conclusions: Our findings reveal important gender differences in AUD patients in their rates of psychiatric and medical comorbidity, substance use and psychosocial functioning, and inpatient service use. The findings in general suggest greater psychiatric problems in female AUD patients. Female patients were also more likely than male patients to have been admitted to inpatient psychiatric units although there were no significant gender differences in outpatient service uses. Finally, after controlling for comorbidity, male patients had greater medical comorbidity even though female patients reported more medical problems, suggesting a possibly complex relationship between gender and medical problems.

Impact: One of the agendas of the VA health care system is to improve access, utilization, and treatment for veteran women. Our findings suggest that assessment and treatment of veteran women with alcohol use or psychiatric disorders will need to be comprehensive given their high rates of comorbidity.

HSR&D Funded: OAA/HSR&D training funds

45. Variation in the Process of Care for Black and White Patients in Veterans Hospitals

Objectives: Racial variations in the utilization and outcomes of health care are well documented; however, few studies have compared quality of care in Black and White patients. The purpose of this study is to examine whether the process of care (quality) differs in Black and White United States veterans.

Methods: Data were from the medical records of patients discharged from one of 12 southern Veterans Affairs Medical Centers (VA) with diabetes (DM; N=678), congestive heart failure (CHF; N=850), or chronic obstructive lung disease (COPD; N=1292). Quality of care was assessed with disease-specific explicit criteria for the process of hospital care. Criteria were developed for the admission work-up, evaluation and treatment, and readiness for discharge for each disease by panels of expert physicians. Adherence scores (percent of applicable criteria met) were produced for admission (ADM), evaluation and treatment (TRT), and discharge (DC) for each patient. Bivariate associations of race with quality (adherence score) were examined with the t-test. After controlling for severity of illness (APACHE II) and other covariates, the independent association of race with quality was determined for ADM and TRT with linear regression and for DC with logistic regression, because DC scores were not normally distributed.

Results: Mean age and mean APACHE score were similar (P>.05) in Black and White patients for DM, CHF, and COPD. Unadjusted mean ADM scores were higher (82.0 vs. 79.4%; P<.001; CHF and 71.7 vs. 68.7%; P<.001; COPD) in Blacks and were also higher (82.7 vs. 73.9%; P<.001; CHF and 66.1 vs. 52.9%; P<.001; COPD) in teaching hospitals. Mean TRT scores were higher (61.5 vs. 58.1%; P=.05; COPD) in Blacks and were higher (66.1 vs. 52.9%; P<.001; CHF and 62.5 vs. 53.3%; P<.001 COPD) in teaching hospitals. Unadjusted mean DC scores were not different (P>.20) by race or teaching hospital in the three diagnoses. Blacks were more likely (P<.001) to be admitted to teaching hospitals. After controlling for age, APACHE score, comorbidities, and other covariates, Blacks had higher ADM scores than Whites with CHF (ß=2.15; P=.006) and COPD (ß=2.89; P<.001), but not with DM (ß=1.25; P=.20). Adjusted TRT score was higher (ß=3.64; P=.03) in Blacks with COPD. Blacks had lower (OR 0.67, 95%CI 0.47-0.95) adjusted DC scores for CHF. However, when we controlled for teaching hospitals, race was not independently associated (P>.05) with ADM or TRT scores for three diagnoses or with DC scores for two diagnoses (COPD,DM), but the DC score for CHF remained lower in blacks (0.67, 95% CI 0.47-0.95) even after controlling for admission to a teaching hospital.

Conclusions: We found that adjusted quality was significantly higher in Blacks at ADM (CHF, COPD) and at TRT (COPD) and was significantly lower in Blacks at DC (CHF). After adjusting for teaching hospitals, quality was similar by race at ADM and TRT for each diagnosis, but remained lower in Blacks at DC for one of three diagnoses (CHF).

Impact: Differences in quality by race may be influenced by higher quality at teaching hospitals and a higher likelihood that Blacks were treated in teaching hospitals.

HSR&D Funded: 89-061

46. The Effect of Race on Survival of Men Hospitalized in the Veterans Affairs Healthcare System

Objectives: Race affects the delivery of healthcare but the effect of race on health outcomes has been inconsistent. Racial disparities are at least partly due to differences in access to healthcare. Prior studies evaluating the effect of race on clinical outcomes have been limited to specific disease conditions or regions of the country. The VA operates a nationwide, government-funded healthcare system with few financial barriers and may allow for improved access to care for black patients. Therefore, we studied the effect of race on mortality for patients admitted to Veterans Affairs (VA) hospitals, a healthcare system that offers potentially equal access to care.

Methods: We studied 39,190 patients admitted to one of 147 VA hospitals during the fiscal year 1996 for one of six common medical conditions: heart failure, ischemic heart disease, diabetes mellitus, pneumonia, chronic obstructive pulmonary disease, or chronic renal failure. Due to relatively small numbers, we excluded women and other racial groups. For patients with more than one hospitalization, a single admission was randomly selected. We used proportional hazard models to adjust for differences in patient demographic characteristics, comorbidity score (based upon number of concurrent illnesses), length of hospital stay, and hospital characteristics. The primary outcomes were unadjusted and adjusted 30-day mortality rates for blacks and whites; we also compared unadjusted and adjusted inpatient and 6-month mortality rates. Finally, we compared adjusted mortality rates after stratification by variables that we hypothesized might interact with race (age, financial status, comorbidity score, length of stay, CABG availability, urban location, region, and disease.)

Results: Mortality at 30 days was 23% lower for black patients compared with whites. This decrease in mortality was observed for each of the six disease categories. After multivariate adjustments, blacks still had lower 30-day mortality than whites [Hazard Ratio (HR) 0.83, 95 percent confidence interval, 0.74 to 0.94, p=0.003]. Black patients also had lower adjusted inpatient mortality (HR 0.86, 95 percent confidence interval 0.78 to 0.98, p=0.03) and 6-month mortality (HR 0.86, 95 percent confidence interval 0.76 to 0.96, p=0.02). These effects were consistent across all subgroups evaluated, and we found no significant interactions.

Conclusions: Black patients admitted to VA hospitals with common medical conditions have lower mortality rates than white patients. This finding was not limited to any particular subgroup and persisted up to six months of follow-up.

Impact: Though the survival advantage of black patients is not readily explained, the favorable outcomes for black patients at the VA are likely due to equal access to healthcare and quality inpatient treatment.

Objectives: The goal of the Veteran Identity Program (VIP) is to understand how factors related to ethnicity and veteran identity influence utilization of ambulatory care and other healthcare services in the VA. Further, it seeks to identify how these factors vary across racial/ethnic groups and to apply these findings to prescribe program and practitioner interventions to improve access of minority veterans to ambulatory care.

Methods: As part of a four year triangulated research design, the VIP project conducted 16 focus groups of users and non-users of the VA healthcare system (n = 178). The design included sampling by two major war cohorts (WWII and Vietnam) and by race/ethnicity (African-American, Asian, Caucasian and Hispanic). Focus groups were held at eight different community sites and facilitated by trained non-VA facilitators of the same racial/ethnic background as participants. Reasons that veterans use or do not use the VA, as well as suggestions for improvement, were assessed. Content analysis of transcriptions was performed using NUDIST, a qualitative software program. Facilitators and barriers to VA use were ranked and illustrative quotes were identified. Veterans’ perception of their military experience was compared to their perception of VA healthcare.

Results: Racial/ethnic and war cohort differences were noted for both perceptions of VA healthcare and suggestions for improvement. Groups with higher positive evaluations of the military had higher assessments of VA healthcare. Caucasians and Asians of all war cohorts, and African-American Vietnam veterans were the most critical of the VA system. The top five barriers or reasons to not use the VA included: employees (including physicians), poor information regarding services, waiting time for and at appointments, denied access, and inconvenience. Illustrative statements include: "The way we became Americans is being WWII veterans. So there’s no reason why we’ve not been given ID cards. I hope you leave that on (the) record." (Asian WWII veteran); "The guys who did what it took to become disabled deserve the benefit. They’re being told by people who have no idea what went on, "so what, and we don’t care."" (Caucasian Vietnam veteran); "I go to a private doctor. They’re more accountable for what they do. At the VA you see doctors that are given to you." (African-American WWII veteran). A common theme in both positive and negative statements was the expectation that the VA should provide specific services that are veteran related, and in a manner that particularly acknowledges their veteran experience, and how it varies by background.

Conclusions: Veterans’ military and racial/ethnic experiences frame their perception of the VA healthcare system, and how negatively or positively they feel about using VA health care services.

Impact: This qualitative data will be used to frame questions for a survey of 3,200 veterans in VISN 22, in order to formulate interventions from the veteran’s perspective for improved access. Customer service training which aims to increase provider and staff sensitivity to minority veteran’s sense of identity based on their unique military experiences deserves examination as a strategy to increase access and satisfaction.

HSR&D Funded: ECV97-028

48. Utilization Patterns of Dually-Eligible (VA and Medicare) Veterans by Age

Objectives: To study utilization patterns of dually-eligible young (under 65) and older (over 65) veterans. Younger veterans account for nearly half of the VA system users and about 25% of them qualify under Medicare eligibility rules (for disability). Understanding the utilization patterns of these younger, dually eligible veterans is important for VA’s plans for Medicare subvention and for managing their care in VA.

Methods: For veterans who used VA in VISNs 1 and 2 at any time during FY 1995-1997, we merged Medicare utilization (Inpatient, Outpatient and Physician visits) for calendar year 1996 with VA utilization files and categorized patients by eligibility status, age, race etc. We studied utilization patterns: use of VA versus Medicare services; inpatient versus outpatient care in both the systems; and for inpatient use, by Major Diagnostic Categories (MDC).

Results: Out of 166,132 dually eligible veterans who used VA at any time during FY 1995-1997, 89% (147,903) had at least one contact with a health care provider in calendar 1996. Of all dually-eligible veterans, 22.3 % were younger than age 65. These younger veterans accounted for nearly 29% of all inpatient stays and 31% of all bed days. Further, this younger population was twice as likely to be admitted in VA than Medicare (17,432 versus 8,615 stays). In contrast, dually-eligible veterans over age 65 are equally likely to be admitted to VA as Medicare. For dually-eligible younger veterans, Mental Diseases and Disorders (25%); and Alcohol and Substance Abuse (20%) accounted for total 45% of total inpatient stays for younger veterans. Diseases and Disorders of the Circulatory System accounted for another 15%. Younger veterans were 2.25 times more likely to be admitted to VA than Medicare for Mental Diseases and Disorders. Older veterans were 1.5 times more likely to be admitted to Medicare than VA for Diseases and Disorders of the Circulatory System (30% of all inpatient stays for that group). Overall, all dually-eligible veterans are 1.5 times more likely to be admitted to VA than Medicare for Diseases and Disorders of the Kidney and Urinary (4.25% of all inpatient stays). This ratio is even higher (3.5) for younger veterans.

Conclusions: Many veterans qualify for Medicare for reasons other than age. Significant numbers of dually-eligible veterans are younger than 65 and their utilization patterns are considerably different than those of veterans over 65. Younger veterans use more inpatient services and are more likely to be admitted to VA than Medicare.

Impact: Younger veterans account for substantial proportion of dually-eligible veterans. Health care needs of these younger veterans are different than those of older veterans, and these differences are important for VA’s Medicare subvention and managed care for these veterans.

HSR&D Funded: IIR MPC 97-0021

49. Liver Transplantation Recipients in the United States in the 1990s: A Comparative Analysis With the U.S. Liver Donor Population

Objectives: Orthotopic liver transplantation (OLT) is a valued and limited resource in the United States. We have previously reported detailed demographic data and economic status on U.S. cadaveric liver donors (1). Currently there is a lack of detailed demographic and socioeconomic data describing the present U.S. population of OLT recipients. The prupose of this study is to describe the current U.S. population of adult, primary OLT recipients and compare this population's demographic data and economic status with that of the U.S. cadaveric liver donor population in order to better understand organ allocation.

Methods: We obtained detailed demographic data on primary OLT recipients (n = 7967, age >= 18 years) for the years 1994-1997 from the United Network for Organ Sharing (UNOS). Comparative data on cadaveric liver donors (n = 10,689) for this same period were also obtained from UNOS.

Results: The mean age of the OLT recipients was significantly older than the liver donors, 49.2 years vs. 40.6 years, p < 0.001. The majority of both OLT recipients and liver donors were male, 58.1% and 58.9% respectively, p = 0.27. As compared with cadaveric liver donors, significantly more OLT recipients were White 89.3% vs. 87.3%, Asian / Pacific Islander 3.1% vs. 2.1%, or Native American / Alaskan Native 0.8% vs. 0.2%, all p values < 0.001. However, significantly fewer OLT recipients were Black 6.8% vs. 10.4%, p < 0.001or non-U.S. citizens, 3.1% vs. 4.8%, p < 0.001. 47.4% of OLT recipients completed high school or attended college / technical school. The majority of OLT recipients, 64.5% reported having "private insurance" while only 28.5% reported Medicaid/Medicare as their primary source of payment at the time of transplant. Compared to the median household income of U.S. cadaveric liver donors, median income in OLT recipients was 8.6% higher, $31,757 vs. $29,231, p = 0.001. This however is still 11.5% lower than the overall current median household income in the United States, $35,492.

Conclusions: Compared to U.S. cadaveric liver donors, primary adult OLT recipients are significantly older, have a significantly higher median household income, and appear less likely to be Black. Specifically, there are significantly fewer Blacks who receive OLT as compared to the number who are cadaveric liver donors. While Whites, Asian / Pacific Islanders, and Native Americans / Alaskan Natives appear over-represented in the OLT recipient group. Lastly, most OLT recipients, especially White recipients (65.6%), had private health insurance, which may help facilitate access to medical evaluation and subsequent organ transplant. These data may allow for a better understanding of the demographic and socioeconomic differences which currently exist between liver organ donors and OLT recipients in the United States. (1)Gralnek IM, Liu HH, Shapiro MF and Martin P. The United States liver donor population in the 1990s: A descriptive, population-based comparative study. Transplantation 1999;67:1019-1023.